ATLANTA--Questions were flying across the industry's sleep sector last week after a recent Local Coverage Determination declared that in-home sleep studies "are not covered."
The LCD surprised providers, particularly since CMS' proposed decision memorandum on coverage for CPAP therapy, issued Dec. 14, would allow home sleep testing.
But not to worry, according to Robert D. Hoover, Jr., senior medical director for Cigna Government Services: The LCD was a Fiscal Intermediary policy update in response to coding changes and has no bearing on CMS' National Coverage Determination--expected no later than March 13--regarding criteria for CPAP coverage.
"The contractors have a mandated schedule for updating our policies when there are HCPCS changes (within 90 days/120 days). Policies with the new CPAP HCPCS codes from Jan.1, 2008, got published without regard to the upcoming NCD. This was a Fiscal Intermediary policy, not a DME MAC update; however, I suspect their policy update is due to the same reason we update our policies--HCPCS code changes," Hoover explained.
The Jurisdiction C medical director also pointed out there could be a bit more confusion to come. With transition of medical review responsibilities from the DME Program Safeguard Contractors to the DME Medicare Administrative Contractors, official as of March 1, the current policies must be posted on the MAC Web sites.
"Once we approve, our policies will also display to the public, and the CPAP policy will be essentially unchanged except for the changes in the HCPCS codes from Jan. 1, 2008. So like the FI policy, ours, too, will still have the same language prohibiting home sleep studies."
Kelly Riley, director of the National Respiratory Network for The MED Group, Lubbock, Texas, said attendees at the network's annual meeting last week also were stumped by the LCD because it had been issued ahead of CMS' anticipated final coverage policy.
"It's just that every time we see the words 'home sleep testing,' we jump," Riley said. "But as strange as this sounds, this [LCD] doesn't have a thing to do with CPAP coverage. This LCD came from a Fiscal Intermediary ... and because of some coding changes, they had to reissue the policy. Every time there is a change in the codes, they are required to reissue the policy so everybody is clear.
"What we have to remember," Riley continued, "is that the NCD is on its way, so we as an industry need to chill."
Under current CMS policy, obstructive sleep apnea patients must be diagnosed through a sleep lab test, or polysomnography, for Medicare to cover the cost of CPAP therapy. But the agency's draft memo recommended changes, which, among others, would allow the use of home sleep testing.
Hoover said the NCD should be out this month as expected. But he speculated that, based on previous decisions, its effective date could be "out to July 1 or maybe even Oct. 1. Once the NCD is final and has an effective date, the [medical directors] will update the CPAP policy with a new effective date that coincides with the NCD effective date and update the coverage language in the policy to reflect the coverage criteria of the NCD."
"I just came out of three days of being with top industry experts on this area," Riley said of MED's meeting, which hosted attendees from more than 70 companies in 32 states, "and we talked about [this] LCD.
"If I had to put this in a simple blurb," she concluded, "I would say 'Sit tight. This LCD does not affect us, and at this point there are really no changes.' This was purely an administrative function of the Fiscal Intermediary, and we are still waiting for the NCD."