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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 home sleep tests (HSTs) may be used in addition to a face to face clinical assessment by the 
treating physician, Epworth Sleepiness Scale, and physical examination to diagnose obstructive sleep apnea 
(OSA); specifically, it is intended only for those patients who exhibit clinical signs and symptoms of OSA. 
 
HST is not covered for patients with certain medical comorbidities, including:  
- Moderate to severe pulmonary disease (e.g., patients on oxygen or regular bronchodilator use)  
- Neuromuscular disease affecting muscles of respiration  
- Congestive heart failure  
- Suspicion of the presence of other sleep disorders, i.e., narcolepsy, parasomnia, or periodic limb movements 
of sleep 
- other respiratory disorders, impotence, restless leg syndrome. 
 
You can find this information in the Local Coverage Determination (LCD): Polysomnography (L36593). 
 
Unattended sleep studies: 95800, 95801, 95806 and G0398, G0399, and G0400: 
The technical component of HST and unattended sleep studies must be provided by an accredited sleep center 
or laboratory and meet the requirements of the LCD for coverage. The only exception would be the global 
billing (professional/technical components [PC/TC]) of HST by an office-based physician who meets the 
requirements under the Physician Training/Certification as noted in the LCD. In this case, the PC/TC for HST 
can be covered for the purpose of testing a patient for the diagnosis of OSA if the home sleep testing is 
reasonable and necessary for the diagnosis of the patients condition as outlined in the LCD; and the office-
based technician doing the patient instruction and HST scoring meet the training/credentialing requirements as 
outlined in the LCD. Under this circumstance, the physician would be the interpreter of the test and bill 
globally. In all other circumstances, the physician who is providing the PC of the HST must be identified 
specifically in the medical record as the interpreter of the test. It should be noted that per LCD 36593 the 
laboratory physician must review the entire raw data recording for every patient studied. Raw data refers to 
data obtained directly from patient output to the acquisition device. All channels to and from the acquisition 
device must be physical channels and not derived, calculated, virtualized, or created by software to create 
channels for the purposes of the test and scoring of the raw data, i.e., a respiratory channel must be a physical channel to and from the acquisition device for the purpose of the test and scoring/analysis of the data. All 
raw/autoscored data must be scored/re-scored by an individual certified by the Board of Registered 
Polysomnographic Technologists as a Registered Polysomnographic Technologist (RPSGT), or equivalent, or 
by a polysomnographic technician under the supervision of a RPSGT, or equivalent, manually even if an 
autoscoring protocol is applied prior to manual scoring/analysis. The name of the scoring RPSGT, supervised 
polysomnographic technologist, or equivalent, as well as an indication the procedure was manually 
scored/analyzed must be on the scoring report or interpretation report indicating manually scored/analyzed. If 
these requirements of the LCD are not met, the procedure cannot be submitted for reimbursement. 
 
You can find this information in Local Coverage Article Billing and Coding: Billing and Coding: 
Polysomnography (A56995). 
 
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.