Sleep2Die4,
Medicare is up front about exactly when they will and will not pay for a CPAP trial. From
the CMS.gov webpage titled,
National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (240.4) is the following language:
Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.
...
3 An initial 12-week period of CPAP is covered in adult patients with OSA if either of the following criterion using the AHI or RDI are met:
- a. AHI or RDI greater than or equal to 15 events per hour, or
b. AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
6. The AHI or RDI is calculated on the average number of events of per hour. If the AHI or RDI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing must be at a minimum the number of events that would have been required in a 2-hour period.
7. Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.
In other words, Medicare will NOT pay for a CPAP to treat UARS if the AHI < 5. Moreover, Medicare will NOT pay for a CPAP to treat OSA if the diagnostic test used Rule 4B to score hypopneas and it is the Rule 4B hypopneas that push the AHI over 5.
NOTE: A Rule 4B hypopnea can be scored under either of the following circumstances:
- There is at least a 50% reduction in thoracoabdominal movement or airflow as compared to baseline and there is at least a 3% oxygen desaturation, OR
- There is at least a 50% reduction in thoracoabdominal movement or airflow as compared to baseline and there is an associated arousal as measured by the EEG data
So what would you do if you ran a sleep clinic where many (or most) of your patients/customers were old enough to be covered by Medicare? Would you bother to look for UARS even if you believed it was a real condition when doing so increases the costs of administering the test and runs the risk of saddling a patient with a diagnosis for which the treatment will NOT be authorized by Medicare?
And would you shy away from scoring Rule 4B hypopneas for Medicare patients as well and for the same reason?
These are NOT academic questions about bizarre far out scenarios: Not everyone has O2 desats with hypopneas.
In my own case, I have some good reasons to believe that some of the scoring on my own diagnostic sleep test may have been "fudged" a bit. And by that I mean this: My insurance company will pay for CPAP if the AHI > 15 and there's no history of daytime sleepiness regardless of whether Rule 4A (Medicare's definition of hypopnea) or Rule 4B is used. And I had no history of daytime sleepiness going into my sleep test; I was sent for a PSG because my hubby was witnessing apneas several times a week and was concerned about them. I had an OAI = 3.5 on my diagnostic sleep test. All of my Rule 4B hypopneas were scored as "hypopneas with arousal" and there were no O2 desats noted on the sleep test; hence none of them would have counted in Medicare's eyes, and if I were a Medicare patient, I would have been told that I had NO OSA at all.
But under Rule 4B my diagnostic AHI = 23.5 or so because of a very large number of "hypopneas with arousal". It's quite likely that many of my "hypopneas with arousal" required a judgement call on the part of the tech scoring the test as to whether the air flow had really been reduced by 50% for 10 seconds, but the increasing respiratory effort was there and the EEG arousals were there. So fudging a bit on what the "baseline" was could well have changed a probable UARS diagnosis (and no coverage for a CPAP titration test and no coverage for a PAP machine) into a clear cut Moderate OSA diagnosis with coverage for both a titration test and a PAP machine.
