I sent a patients file to CGS Connect because I didn’t think he would qualify. Here is the exchange:

*I have a question on this decision. You have indicated that the documentation supports the requirements for an E0601. I am curious what led to this decision. The issue I was having is that this patient currently has a PAP device but does not have any claim history with Medicare of one, which would indicate to me that they are a beneficiary entering Medicare. We asked the referral source for the sleep study prior to enrollment , which they were unable to provide. So they went with a new sleep study - which now makes it a “new” patient, correct? In this case, per the LCD’s cited (L33718), we would need: “A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.”. The in person face to face provided, dated 3/12/2024, makes no mention of OSA, the only thing mentioned is the need for a replacement CPAP, and they are ordering a sleep study. The new sleep study was done 5/7/2024 where they qualified for a PAP device. The only other notes provided were after the sleep test. There is nothing available that shows they qualified for the original machine. Is the fact that the physician documented the use/need for a CPAP enough to order a new test and qualify for the device?

Yes, that is correct because the MD documented beneficiary has been on CPAP for over 5 years and device is broken. New sleep study was done with documented diagnosis of OSA with AHI of 13.1 with HTN, the case would be supported.