Reverse Reimbursement Cuts and Expand Coverage for Cpt 41530-Radiofrequency Tongue Base Volume Reduction Treatment for Obstructive Sleep Apnea

Radiofrequency Tongue Base Volume Reduction (RTBVR), CPT 41530, is a safe, timely, efficient, effective, equitable and patient-centered in-office procedure designed to improve, and at times eliminate, the adverse health consequences of Obstructive Sleep Apnea (OSA).

RTBVR is the only FDA Approved Minimally-Invasive Therapy proven effective in managing OSA in the office setting. RTBVR may be performed under local or intravenous anesthesia, eliminating the requirement for general anesthesia in the hospital setting. RTBVR has been covered by CMS since 2009 but recently has been considered a mis-valued (over-valued) service.

CMS has drastically reduced 2016 RTBVR Reimbursement by 69 percent. Physicians are no longer able to offer the procedure as a cost effective alternative to CPAP or more expensive and invasive hospital-based procedures.

In addition, CMS MAC Part A/B Carriers are inconsistent in their coverage of CPT 41530. Although CMS has NO National Coverage Determination (NCD), two MAC Carriers, Wisconsin Physician Services (WPS) and First Coast Service Options (FCSO) have a Local Coverage Determination (LCD) listing CPT 41530 as a "Non-Covered Service." These LCD's restrict ALL Medicare Beneficiaries in (1)Iowa, (2)Kansas,(3)Missouri,(4)Nebraska, (5)Indiana,(6)Michigan and (7)Florida access to RTBVR. The other 43 States have MAC Carriers that list CPT 41530 as a "Covered-Service." In addition, WPS is a MAC Part A Carrier for 40 States. WPS invokes their restrictive LCD on RTBVR performed in the hospital setting. In 33 of these States, the MAC Part B Carrier allows RTVBR to be provided in the office but WPS restricts the same Medicare Beneficiary from having it performed in the Hospital setting.

Patients overwhelming prefer the in-office setting for RTBVR and find it highly cost effective at the 2015 Office-based CMS Fee Schedule. Based on a study by Harvard Medical School Division of Sleep Medicine. The price of fatigue: the surprising costs of unmanaged obstructive sleep apnea. Boston, MA: Harvard Medical School; 2010, RTBVR saves the US Economy over $186,000 per each successfully treated patient. With a success rate over 45 percent, this translates to an effective net savings over $90,000 per treated patient.

As a Federal Health Program, Medicare Beneficiaries should have access to CPT 41530 in all 50 States and in all treatment settings, Hospital, Ambulatory Surgery Center or Office setting.