Optimal NIV Medicare Access Promotion: Patients With Central Sleep Apnea

Abstract

This document summarizes suggestions of the central sleep apnea (CSA) Technical Expert Panel working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, CPAP and oxygen therapy are recommended but not covered for CSA. On the other hand, bilevel positive airway pressure (BPAP) without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or BPAP in the spontaneous mode, even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation, even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another; an example is switching from BPAP with backup rate to an adaptive servoventilation with automatic end-expiratory pressure adjustments, which may not be covered. To address these challenges, we suggest several changes to the coverage determinations, including: (1) a single simplified initial and continuing coverage definition of CSA that aligns with OSA; (2) removal of hypoventilation terminology from coverage criteria for CSA; (3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms; and (4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

Contribution of central sleep apnea to severe sleep apnea hypopnea syndrome

“…Continuous positive airway pressure ventilation (CPAP) may be used to treat suspected OSA directly. But for those patients with a component of CSA, there may be a greater possibility of complex sleep apnea syndrome or lower adherence to CPAP therapy [ 8 – 10 ]. The home sleep apnea test (HSAT) detects OSA in a cost-effective manner but does not distinguish CSA [ 8 , 11 ].…”

“…But for those patients with a component of CSA, there may be a greater possibility of complex sleep apnea syndrome or lower adherence to CPAP therapy [ 8 – 10 ]. The home sleep apnea test (HSAT) detects OSA in a cost-effective manner but does not distinguish CSA [ 8 , 11 ]. To allocate medical resources optimally and to ensure appropriate treatment, it is important to be alert for CSA in patients with SAHS irrespective of which apnea subtype predominates.…”

Enhanced expiratory rebreathing space for high loop gain sleep apnea treatment

“…Although studies suggest that adaptive servo ventilators are superior to CPAP for treatment of the respiratory features of complex sleep apnea, the impact on sleep quality and clinical outcomes is less striking (Morgenthaler et al, 2014). The expense of these machines and strict coverage criteria are challenges (Morgenthaler et al, 2021).…”

“…However, oxygen monotherapy cannot overcome upper airway resistance. In addition, it can be difficult to qualify for in the context in the US insurance system, and selfpay has a significant long-term expense world-wide (Morgenthaler et al, 2021).…”