Boyd K. Honeycutt, MD, MBA, FACP
CIGNA Government Services
4135 Mendenhall Oaks Pkwy # 101
High Point, NC 27265
Boyd.honeycutt@cigna.com
www.cignamedicare.com
Dear Dr. Honeycutt:
The members of the North Carolina Sleep Technologists Association
(NCAST) are writing in regards to the recent draft proposal issued
by the Centers for Medicare & Medicaid Services (CMS): Continuous
Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep
Apnea (OSA) (NCD 240.4) We are concerned this proposal does not
include defined, comprehensive policies about home sleep testing
and this omission has a negative impact on clinical practice and
patient care.
Our organization is comprised of sleep technologists and technicians,
physicians, and sleep advocates which expect the highest of standards
for the profession of polysomnography. By allowing the implementation
of your proposal, the “Use of Unattended Portable Monitors
in the Diagnosis of Obstructive Sleep Apnea in Adult Patients,”
you are compromising the safety and well being of the people of
North Carolina. This would set the profession of polysomnography
and the quality of care back many years, acknowledging your lack
of knowledge of interpreting and diagnosing not one, but many
sleep disorders.
Home sleep testing has been comprehensively addressed by the American
Academy of Sleep Medicine (AASM), which is the governing body
in sleep medicine, in the December 2007 publication of “Clinical
Guidelines for the Use of Unattended Portable Monitors in the
Diagnosis of Obstructive Sleep Apnea in Adult Patients.”
The AASM also sent a response to CMS that outlines several issues
in the proposed NCD:
In agreement with the AASM the members of NCAST acknowledge the
proposed decision is broad. However, we believe with AASM that
important topics are not addressed in the proposed decision:
1. Documentation of OSA and determination of severity by diagnostic
testing is essential for proper management of patients with this
disorder. Severity level is the best predictor of cardiovascular
morbidity and predicts success with different modes of treatment,
especially in those with severe disease. In-lab attended polysomnography
provides the most accurate method for establishing a diagnosis
of OSA and risk stratification as well as providing an opportunity
to initiate CPAP in high risk individuals via a split-night protocol.
2. The proposed decision does not define an acceptable CPAP trial.
3. The proposed decision does not define the requirements for
clinical evaluation that complements the HST.
4. The proposed decision does not define a paradigm for follow-up
and long-term management, especially in patients with negative
home study test or failed CPAP trials.
5. CMS must clarify who is covered by the NCD
- Does the NCD only affect beneficiaries enrolled in Medicare
after implementation of the NCD?
- Does the NCD affect all Medicare beneficiaries?
- Does the NCD affect all Medicare beneficiaries who already utilize
CPAP therapy?
6. The average life of a CPAP machine is 5 years. As such, will
CMS require patients who utilize CPAP therapy to undergo an additional
12-week diagnostic period when a new machine is needed?
This proposal is obviously not in the best interest of the patients
for many reasons, but appears to be in the interest of the bureaucracy
of insurance. A proposal as such would not be effective in treatment
or cost, and expressly detrimental to the health of the patients
involved in this type of testing. If you sincerely care about
the health, safety, and well-being of the patients, then you will
consider our concerns as sleep professionals.
Respectfully submitted,
Will Underwood, RPSGT
President, North Carolina Association of Sleep Technologists
