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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 say that effective for claims with dates of service on and after March 3, 2009, the Centers for 
Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep 
tests identified below can be used by a beneficiarys treating physician to diagnose OSA, that the use of such 
sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA 
and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act. 
1. Type I PSG is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and 
symptoms indicative of OSA if performed attended in a sleep lab facility. 
2. Type II or Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries 
who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab 
facility or attended in a sleep lab facility. 
3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when 
used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if 
performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 
4. Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral 
arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms 
indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility. 
 
You can find this rule in National Coverage Determination (NCD) for Sleep Testing for Obstructive Sleep 
Apnea (OSA) (240.4.1) - Effective March 3, 2009. 
 
The rules say that diagnosis of obstructive sleep apnea requires documentation of: 
 
-Apnea-Hypopnea Index (AHI)/Respiratory Disturbance Index (RDI) greater than or equal to 15 events per 
hour, or 
-AHI 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 
 
You can find this rule in the Local Coverage Determination (LCD) - Outpatient Sleep Studies (L35050) - 
Effective January 1, 2021. 
 
The rules say that out of sleep center testing (OCST) is not appropriate for the diagnosis of OSA in patients 
with significant comorbid medical conditions or comorbid sleep disorders that may degrade the accuracy of PM, including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive 
heart failure. 
 
-For patients unable to be studied in the sleep laboratory when such a study is not possible by virtue of 
immobility, safety, or critical illness. 
-For follow-up studies when diagnosis has been established by standard polysomnography and therapy and 
there is a material change in patients symptoms or complaints, again in the patient with no comorbid 
conditions. May also be indicated to monitor the response to non-CPAP treatments for sleep apnea. 
-When initiation of treatment is urgent and standard polysomnography is not readily available. 
 
You can find this rule in the Local Coverage Determination (LCD) - Outpatient Sleep Studies (L35050) - 
Effective January 1, 2021. 
 
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.