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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 abnormal breathing events in sleep apnea syndromes include apnea, hypopnea and 
respiratory effort related arousals (RERA). Apnea is a cessation of airflow for at least 10 seconds. Hypopnea is 
an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal 
movement or airflow as compared to baseline, and with at least a 4% decrease in oxyhemoglobin saturation. 
RERA is defined as a period during sleep lasting at least 10 seconds during which severe narrowing of the 
upper airways with increasing respiratory efforts leads to electroencephalographic arousal from sleep without 
an appreciable reduction in airflow and oxygen saturation.  
 
Apneas can be classified as central, obstructive or mixed based on the presence of respiratory effort during the 
event. In obstructive apnea events, respiratory effort continues in the absence of airflow while in central apnea 
events, both airflow and respiratory effort are simultaneously absent. Mixed apnea events contain respiratory 
effort only during a portion of the apnea event.  
 
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: 
 
Sleep history and symptoms including, but not limited to, snoring, daytime sleepiness, observed apneas, 
choking or gasping during sleep, morning headaches; and, 
Epworth Sleepiness Scale; and, 
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:  
 
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, 
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:  Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
Hypertension, ischemic heart disease, or history of stroke  
OSA occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and 
block the upper airway. This leads to partial reductions (hypopneas) and complete pauses (apneas) in breathing 
during sleep. Most pauses last between 10 and 30 seconds, but some may persist for one minute or longer. This 
can lead to abrupt reductions in blood oxygen saturation. OSA characterized by RERA events has been called 
upper airway resistance syndrome. In central sleep apnea, the airway is not blocked but respiratory 
coordination is impaired such that the brain does not signal the muscles of respiration to contract. All sleep 
apnea syndromes disrupt sleep, leading to excessive daytime sleepiness, fatigue and cognitive disturbances. 
OSA has also been associated with elevated risk for arterial hypertension, cardiac ischemic events, cerebral 
vascular accidents, insulin resistance and obesity.  
 
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.