Appeal type: unknown
Decision: unknown

 
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 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 obstructive sleep apnea 
(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 polysomnography (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. 
 
The rules say that effective for claims with dates of services on and after March 3, 2009, other diagnostic sleep 
tests for the diagnosis of OSA, other than those noted above for prescribing continuous positive airway 
pressure (CPAP), are not sufficient for the coverage of CPAP and are not covered. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 240.4.1. 
 
   
The rules state that for a diagnosis of OSA to be made, the following criteria must be met: 
 
A. Prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the 
patient for OSA which must include, at a minimum, the following: 
 
1. Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
2. Epworth Sleepiness Scale; and, 
3. Physical examination that documents body mass index, neck circumference and a focused cardiopulmonary 
and upper airway system evaluation. 
 
B. The patient has a covered sleep test that meets either of the following criteria: 
 
1. The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to 15 events 
per hour with a minimum of 30 events; or,  
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 
10 events and documentation of: 
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
b. Hypertension, ischemic heart disease, or history of stroke 
 
You can find this information in the 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.