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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that a titration polysomnography (PSG) provides useful information on the appropriate level of CPAP during one single night in a dedicated environment. Other factors, such as body and neck or mandibular position, weight changes, and nasal obstruction may affect the appropriate CPAP level. Since these effects may change over time, automatically-adjusting positive airway pressure devices (APAP) were developed. APAP devices are designed to automatically match the treatment pressure to the patient's needs. APAP devices react to perceived treatment pressure needs by manufacturer specific processes such that the information derived from APAP may differ by device and manufacturer. Certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant co-morbidities such as congestive heart failure, chronic obstructive pulmonary disease, central sleep apnea syndromes and hypoventilation syndromes. Similarly, certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients previously diagnosed with moderate to severe OSA without the significant co-morbidities earlier described. A clear patient preference for APAP over manual CPAP has not been demonstrated by studies addressing the issue. Bilevel positive airway pressure (BPAP) is a positive pressure treatment alternative to CPAP that delivers different pressures during exhalation and inhalation. The inhalation pressure does not adapt to the patient's changing needs, as in the APAP, but the exhalation pressure can be adjusted lower. The ability to set different inhalation and exhalation pressures results in lower average airway pressures than those delivered by CPAP. Using lower pressures may reduce the incidence of side effects, such as the sensation of suffocation, difficulty exhaling, nasal congestion, etc. which contribute to patient noncompliance. A clear patient preference for BPAP over CPAP has not been demonstrated by studies addressing the issue. Split-Night Studies Split-night studies involve polysomnography in the first half of the night followed, if there is an abnormal frequency of apneas and hypopneas, by PAP titration for the remainder of the night. Polysomnography with PAP titration is indicated in patients with sleep apnea previously diagnosed by a clinical evaluation and either a positive PSG or a positive HST. Typically split-night studies are performed for two major reasons: 1. When a positive diagnosis (described below) of sleep apnea (obstructive, central or mixed) can be made within the first 4 hours of polysomnography. This could include emergency protocols where patient's apnea is not safe to continue testing without PAP treatment 2. In patients with a prior history of OSA who need an updated polysomnography and PAP titration. For Positive Airway Pressure (PAP) titration, a split-night study (initial diagnostic polysomnogram followed by PAP titration during polysomnography on the same night) is an alternative to one full night of diagnostic polysomnography, followed by a second night of titration for the treatment of obstructive sleep apnea (OSA) if the following criteria are met: A positive test for OSA is established if either of the following criteria using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is met: -AHI or RDI greater than or equal to 15 events per hour, or -AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke
-There are at least three hours for PAP titration prior to the end of the test. You can find these rules in Local Coverage Determination (LCD): Polysomnography and Sleep Testing (L33405).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.