Use it or lose it: Medicare's new paradigm for durable medical equipment coverage?

The 2008 National Coverage Determination by the US Centers for Medicare and Medicaid Services (CMS) authorizing coverage of positive airway pressure (PAP) treatment of obstructive sleep apnea on the basis of diagnosis by portable monitoring was seen by some as a major advance in reimbursement policy for sleep medicine services. However, along with the national coverage decision came additional rules (local coverage determinations) setting forth the conditions that would apply in order for reimbursement to continue beyond 90 days. These rules specified the means by which adherence must be measured, a rigid threshold for the acceptable degree of adherence, and a requirement for face-to-face evaluation by the clinician to document clinical response, all of which must take place within a specific timeframe. Whether CMS or the local carriers anticipated the difficulties that would be experienced by clinicians, durable medical equipment (DME) companies, and patients in complying with these rules is unknown. What has become abundantly clear to many is the burden that these rules impose on clinicians and DME providers and, more importantly, that indiscriminate enforcement may well result in adverse consequences for some patients. The latter include not only the inconvenience and added expense for patients of complying with the rules, but those resulting from failure by CMS to recognize that a dose-response relationship exists with respect to the degree of PAP adherence and clinical outcome. Moreover, there is reason to believe that patients of low socioeconomic class, or who are unmarried, or who have psychiatric disease will have more difficulty achieving the required adherence and therefore will, in effect, be victims of government-mandated discrimination in the provision of a vital healthcare service.