‘CPAP Mask of Choice’ Is Now OK for Medicare Beneficiaries

By Sree Roy

In February 2024, the four Durable Medical Equipment Medicare Administrative Contractors (DME-MACs) issued a “Dear Physician” letter detailing recently established guidelines for completing a CPAP mask standard written order.

“To promote patient adherence,” the letter states, “general descriptions”—such as “mask of choice,” “mask—fit to comfort,” or even simply “CPAP mask”—as opposed to “specific mask type (ie, full face mask)” or specific branded masks are now acceptable. This also means “it is not necessary to document in the patient’s medical record the rationale for a specific mask/interface type.”

Durable medical equipment suppliers (DMEs) had pestered the DME-MAC medical directors for years for this change. “It took a while, but they finally got it. And we appreciate it. It’s been huge for our industry,” says Ronda Buhrmester, senior director of payer relations and reimbursement at VGM Group Inc, an organization with several thousand member DMEs across the United States.

Previously, when a physician signed a generic order, like “CPAP mask of choice,” Medicare wouldn’t reimburse the DME for the mask—which meant the DME volleyed the prescription back to the physician so specifics could be added, delaying the patient’s therapy start. “That was just ridiculous,” Buhrmester says.

The ability to use a generic standard written order for Medicare beneficiaries also “will eliminate the need for a new [standard written order] each time a patient switches their mask type,” states the “Dear Physician” letter. That’s versus a prescription listing a specific type (or brand), which locks the patient in and requires a new prescription for a mask change.

Supporters of Generic CPAP Mask Orders

CPAP mask makers generally support the increased flexibility, even if it results in fewer standard written orders for their branded masks.

“It’s all about freedom and time wasted when trying to find the interface that works best for them,” says Kelly Rudolph, president of mask maker Hans Rudolph Inc. “Waiting for doctors, sleep techs, and insurance slows down the process of finding what is going to be the best way for the [obstructive sleep apnea] patients to comply with their CPAP therapy requirement.”

Carlos M. Nunez, MD, chief medical officer at ResMed, says, “The flexibility might look like a negative to some, but the change makes it easier to get more people on therapy. As the tide rises, all boats will rise.” Nunez’s perspective is framed by his confidence that many patients will select ResMed masks, even without a branded prescription. “If we don’t have the most comfortable mask, shame on us,” he says.

Rahul Gundala, MBA, business category leader of patient interfaces at Philips, points out that being able to switch CPAP masks quickly, without waiting for a new physician order, is a big plus. “In the time between a diagnosis, therapy setup, and when the patient becomes adherent to therapy, a lot can change,” Gundala says. “The new [standard written order] allows for the clinical team to make necessary mask changes more freely to ensure the patient is both comfortable and compliant. There are so many options between types, brands, and cushion/headgear sizes that the power of choice can truly add efficiency to the process.”

First-time patients “don’t always know what makes them comfortable,” Gundala adds. “And even if the first decision is a good one, circumstances may change (such as nasal congestion, change in body type, etc), so having the flexibility to switch mask types…is truly good for long-term adherence.”

Developers of CPAP remote mask fitting software also express support. “It does open some flexibility for the DME for that initial mask being dispensed,” says Bianca Lehman, MBA, RN, CDME, vice president of Baxter Technology Group, marketers of SleepGlad software. “It gives the DME the flexibility to be able to use something like a mask-fitting solution, provide that mask, and send the results back to the physician and say, ‘This is the mask we dispensed.’”

William Kaigler, MBA, cofounder and CEO of sovaSage Inc, which also markets CPAP mask-fitting software, says, “The ongoing advances in mask design call to attention the fact that the best mask today may not be the best mask forever for a given patient, and tools like this help to constantly optimize this choice.”

Concerns Raised About Whose ‘Choice’ the Mask Becomes

When Amy J. Aronsky, DO, FAASM, practiced at a sleep disorders center in 2019, she only wrote branded CPAP mask prescriptions. “I found in my practice that the mask was critical to compliance,” says Aronsky, now senior medical director at UnitedHealthcare. “I wrote the name of the mask specifically and ‘dispense as written.’”

Writing “mask of choice” can be a “slippery slope,” she says, “because it ends up not necessarily being the mask of the patient’s choice but the mask the DME has in stock.” Aronsky says, “They may stock only one nasal pillow and one full-face mask. They’re not going to have the full array of choices that a sleep center has.”

For patients who were happy with the CPAP mask they wore during a titration study, Aronsky is also concerned that a “CPAP mask of choice” won’t meet their expectations. “They slept with that mask. They feel comfortable with it, and now you have a DME company that has maybe a secondary, or primary, intention to try to hold on to money, to make money, and to sell them a less expensive mask.” (Because Medicare reimburses all CPAP interfaces of the same type, such as all full-face masks, at the same rate, DMEs can increase profits by dispensing brands in each category that cost the DME less.)

Because the sleep industry has moved even further toward the home sleep testing to APAP pathway since she last practiced in 2019, meaning fewer patients try on masks at a sleep disorders center, Aronsky concedes that the patient expectation concern may not be as relevant in 2024. Still, she says, “I’m a physician, so I’m biased. But I think the change favors the DME company rather than the patient.”

Sleep Lab and DME Expertise

Even when the patient has an in-lab titration study, posits Buhrmester of VGM, a one-night experience is not the best determination of a patient’s mask choice. “The sleep lab environment is a whole different environment than when they’re going home. Once they’re at home and using that machine day to day, that will change how that mask works and fits for them,” she says.

The expertise of the sleep disorders center is in diagnosing and determining each patient’s CPAP pressure settings, Buhrmester says. “If there’s a mask that works on a patient, that’s great, but that’s not a primary source for the mask,” she says. “The sleep lab needs to understand that the DME industry are experts in their field. It’s not just anybody on the street dispensing these products. They have staff who are trained and understand how to work with the patients and get them the products they need to get and stay compliant.”

And if DMEs aren’t placing patients in appropriate masks, it’s time to switch suppliers, she says. “The majority of the suppliers do good business, and I have not heard a single supplier say, ‘Oh, now that we have this flexibility where it can just say ‘CPAP masks,’ we’re just going to start dispensing these generic ones,’” she says. “If a supplier isn’t providing good customer service to patients, then find a new supplier. They exist.”

Excessive Mask Switching?

Another potential risk is that patients who blame all their CPAP challenges on the masks will have an easier time repeatedly switching masks. “CPAP therapy requires some adjusting and does take time. With this flexibility, some patients might simply push the DMEs for a change in mask without truly understanding the tradeoffs,” Gundala says.

On the other hand, for patients who would benefit from a mask switch, “a lot seem to be ignorant of the fact that they can return the mask if it’s not satisfactory to them,” Aronsky says. Patients should be informed (ideally by the DME, in Aronsky’s view) if their mask is exchangeable within the first 30 days (most mask manufacturers have such programs).

However, the Dear Physician letter cautions, “While this flexibility allows for changes in mask types each month, treating practitioners are reminded that Medicare covers only one mask every three months, regardless of the number or type of mask prescribed for an individual patient.”

Gundala says, “The simplification of mask switches is a great step in the right direction; however if the benefits need to be captured long term, reimbursement should also consider this mask rotation rather than depending on manufacturer programs.”

Buhrmester adds that sleep physicians should ensure that resupply is explicitly included in the initial standard written order. “That way, they don’t have to worry about another order coming through from that supplier. The order can be ‘CPAP mask, one every three months,’” she says, adding that saving an electronic medical record template with the verbiage can be a time-saver.

Specific Mask Orders Still OK

The updated CPAP mask written order guidelines still allow physicians to specify mask type and write branded prescriptions. They also allow for multiple mask types to be listed so that “suppliers are able to provide the mask that works best for the patient.”

But ultimately DME suppliers hope this change they pushed for means more physicians will write generic standard written orders, giving them flexibility and reducing dispensing delays. “This really opened up a lot of opportunity,” Buhrmester says. “We can just work with the patient to determine what’s best for them to get them compliant. That’s the ultimate goal.”