**History/Background and/or General Information**  

About 40 million people in the United States suffer from sleep problems every
year. Not getting enough sleep for a long time can cause health problems. Many
sleep disorders can be managed by primary care physicians; however, when
abnormal sleep patterns are not easily explainable and further evaluation is
necessary, expert opinion and sleep studies may be needed.

Sleep consists of two distinct states: rapid eye movement (REM), and non-rapid
eye movement (NREM). REM sleep is when we dream. NREM sleep is further divided
into three stages. Stages one and two are referred to as light sleep and stage
three as deep sleep. The first sleep cycles each night contain relatively
short REM periods and long periods of deep sleep. As the night progresses, REM
sleep periods increase in length while deep sleep decreases. By morning,
people spend nearly all their sleep time in stages one, two, and REM.

Polysomnography (PSG) refers to the continuous and simultaneous monitoring and
recording of various physiological and pathophysiological parameters of sleep
furnished in a sleep laboratory facility that includes physician review,
interpretation and report. A technologist supervises the recording during
sleep time and has the ability to intervene, if needed. The studies are
performed to diagnose a variety of sleep disorders and to evaluate a patient's
response to therapies such as continuous positive airway pressure (CPAP). PSG
is distinguished from sleep studies by the inclusion of sleep staging, which
requires electroencepholograpm (EEG), electroculogram (EOG), and
electromyography (EMG).

Parameters 1-3 are required for a basic PSG. Additional parameters that may be
monitored include, but are not limited to, the following:

  1. At minimum, a 3 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp. 

  2. Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye. 

  3. A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, and/or masseter regions. 

  4. Rhythm electrocardiogram (ECG). 

  5. Nasal and oral airflow via both thermistor and nasal pressure sensor for PSG sleep staging with 4 or more additional parameters of sleep. 

  6. Airflow in the mask if positive airway pressure for PSG sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation. 

  7. Respiratory effort by chest-wall and abdominal movement measured using respiratory inductive plethysmography, endoesophageal pressure or by intercostal EMG or validated Polyvinylidene Fluoride (PVDF) impedance belt. 

  8. Oxygen saturation (SpO2) by oximetry or transcutaneous monitoring. 

  9. Bilateral anterior tibialis muscle activity, motor activity-movement using EMG. 

  10. Body positions by directly applied sensors or by direct observation. 

  11. Sound recordings to measure snoring. 

  12. Continuous video monitoring. 

Optional parameters that can be monitored in a sleep study include the
following:

  * Core body temperature
  * Incident light intensity
  * Penile tumescence
  * Pressure and pH at various esophageal levels 

PSG and other sleep test monitoring devices are generally classified based on
the number of biologic sensors applied and physiologic parameters recorded.

  * **Type I** PSG is covered when used to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility. Type I devices are capable of recordings of all of the physiologic parameters and signals defined for PSG. The recording is furnished in a sleep laboratory facility in which a technologist is physically present to supervise the recording during sleep time and has the ability to intervene if needed. Minimal requirements include recording of EEG, EOG, chin EMG, anterior tibialis EMG, ECG, airflow, respiratory effort and oxygen saturation. Body position must be documented or objectively measured. Trained personnel must be in constant attendance and able to intervene.
  * **A Type II** sleep testing device is 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. Type II devices are portable devices that may measure the same channels as type I testing, except that a heart-rate monitor can replace the ECG. This device has a minimum of 7 channels (e.g., EEG, EOG, EMG, ECG-heart rate, airflow, respiratory effort, and oxygen saturation - this type of device monitors sleep staging). A sleep technician is not necessarily in constant attendance in Type II studies but is needed for preparation.
  * **A Type III** sleep testing device is 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. Type III devices monitor and record a minimum of 4 channels and must record ventilation or airflow, heart rate or ECG, and oxygen saturation. A sleep technician is not necessarily in constant attendance in Type III studies but is needed for preparation.
  * **A Type IV** sleep testing device measuring three or more channels, one of which is airflow, is 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. Type IV devices must include airflow as one of the required 3 channels. Other measurements may include oximetry and heart rate. A sleep technician is not necessarily in constant attendance in Type IV studies but is needed for preparation.
  * A sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone is 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. A sleep technician is not necessarily in constant attendance in such studies but is needed in preparation. 

Multiple sleep latency testing (MSLT) involves four or five 20-minute nap
opportunities offered at 2-hour intervals. MSLT objectively assesses sleep
tendency by measuring the number of minutes it takes the patient to fall
asleep. Conversely, the maintenance of wakefulness test (MWT) requires the
patient to try to stay awake. MSLT is the better test for demonstration of
sleep-onset REM periods, a determination that is important in establishing the
diagnosis of narcolepsy. To insure validity, proper interpretation of the MSLT
can only be made following a polysomnography performed on the preceding night.

Normally, sleep studies and PSG for sleep disorders are performed in sleep
centers or laboratories. However, the diagnosis of OSA for coverage of CPAP
may also be established by home sleep testing (HST) as indicated under Sleep
Apnea below.

If HST is used, they may be tested in the home environment after application
of the sensors and receiving education regarding a monitoring device from the
technical, professional, or appropriately trained staff of the sleep center or
laboratory. The overnight stay in the sleep center or laboratory is considered
an integral part of PSG, MSLT, and MWT but not for HST.

**Covered Indications**  

Please refer to CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 70 for sleep disorder clinics definitions and criteria for
coverage of diagnostic tests, and medical conditions for which testing is
covered.

**1\. Sleep Apnea:**  

Please refer to CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 70 B. Medical Conditions for Which Testing is Covered.

Please refer to CMS IOM Publication 100-03, _Medicare National Coverage
Determinations (NCD) Manual_ , Chapter 1, Part 4, Section 240.4 Continuous
Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) and
Section 240.4.1 Sleep Testing for Obstructive Sleep Apnea (OSA) for
indications and limitations.

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:

  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: 
    1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
    2. 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.

The diagnosis and severity of sleep apnea syndromes is established by the
clinical evaluation and a positive PSG or HST. Staging of the severity of
sleep apnea can be accomplished by utilization of the apnea-hypopnea index
(AHI) which is defined as the average number of apneas and hypopneas per hour
of sleep. The respiratory disturbance index (RDI) is another term used to
establish the diagnosis of sleep apnea and stage its severity, which in sleep
tests that measure sleep with EEG is defined as the average number of apneas
and hypopneas, and RERA per hour of sleep. In Type III, Type IV HST, and in
HST devices measuring three or more channels that include actigraphy,
oximetry, and peripheral arterial tone where sleep is not measured, the RDI is
defined as the average number of apneas and hypopneas per hour of recording.

Positive airway pressure (PAP) therapy is a non-invasive technique for
providing continuous (CPAP) or variable levels of air pressure from a flow
generator, via a nose mask, through the nares. The purpose is to prevent the
collapse of the oropharyngeal walls and the obstruction of airflow during
sleep, which occurs in OSA. CPAP is the most commonly used treatment for OSA.
The appropriate level for CPAP is best determined during a CPAP titration PSG.
A titration 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
  * There are at least three hours for PAP titration prior to the end of the test.

**2.** **Narcolepsy:  **

Please refer to CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 70 B. Medical Conditions for Which Testing is Covered.

Narcolepsy can occur with and without cataplexy (sudden, brief loss of muscle
tone with retained consciousness precipitated by strong emotion).

A clinical history, sleep diaries, PSG, and MSLT are key items in the
evaluation of narcolepsy. PSG followed by MSLT is useful in confirming the
clinical impression. Narcoleptic patients often report disrupted sleep, and
PSG often confirms fragmented sleep patterns. Ordinarily, a diagnosis of
narcolepsy can be confirmed by demonstrating mean sleep latency of 8 minutes
or less and two or more sleep onset sleep periods on prior night PSG and MSLT.

The diagnosis of narcolepsy is usually confirmed by PSG followed by a MSLT.
The following measurements are normally required to diagnose narcolepsy:

  * PSG assessment of the quality and quantity of nighttime sleep and to exclude alternate pathology such as
  * OSA;
  * MSLT derived mean sleep latency;
  * The number of REM onset sleep episodes on the PSG and MSLT. 

Initial PSG and MSLT occasionally fail to identify narcolepsy. Repeat PSG may
be indicated if:

  * The first study is technically inadequate due to equipment failure; 

  * The subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; 

  * Initiation of therapy or confirmation of the efficacy of prescribed therapy is needed; or 

  * The results were inconclusive or ambiguous. 

**3\. Other Respiratory Disorders:**

This diagnostic category includes breathing disorders that are not principally
defined by obstructive or central apnea/hypopnea or the upper airways
resistance syndrome.

PSG is indicated for patients with neuromuscular disorder and sleep-related
symptoms to evaluate symptoms of sleep disorder that are not adequately
diagnosed by obtaining a sleep history, assessing sleep hygiene, and reviewing
sleep diaries.

PSG and HST are not indicated to diagnose chronic lung disease. Nocturnal
hypoxemia in patients with chronic obstructive, restrictive, or reactive lung
disease is usually adequately evaluated by oximetry and does not require PSG
or HST. However, if the patient's symptoms suggest a diagnosis of obstructive
sleep apnea or periodic limb movement disorder, indications for PSG are the
same as for those disorders in patients without chronic lung disease.

**4\. Parasomnia:**

Please refer to CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 70 B. Medical Conditions for Which Testing is Covered.

In parasomnia, PSG is routinely indicated:

  * To assist with the diagnosis of paroxysmal arousals or other sleep disruptions that are thought to be seizure related when the initial clinical evaluation and results of a standard EEG are inconclusive.
  * In evaluating sleep-related behaviors that are violent or otherwise potentially injurious to the patient or
  * When evaluating patients with sleep behaviors suggestive of parasomnias that are unusual or atypical because of the patient's age at onset; the time, duration, or frequency of occurrence of the behavior; or the specifics of the particular motor patterns in question (e.g. stereotypical, repetitive, or focal). 

In parasomnia, PSG may be indicated under the following circumstances:

  * In situations with forensic considerations (e.g., if onset follows trauma or if the events themselves have been associated with personal injury).
  * When the presumed parasomnia or sleep-related epilepsy does not respond to conventional therapy.
  * PSG is not routinely indicated in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated. 

**5\. Restless Legs Syndrome and Periodic Limb Movement Disorder:**

Restless legs syndrome is a neurologic disorder characterized by disagreeable
leg sensations that usually occur at rest or before sleep and are alleviated
by motor activity. Periodic limb movements are involuntary, stereotypic,
repetitive limb movements that may occur during sleep and usually involve the
legs and, occasionally, the arms. Periodic limb movements during sleep often
accompany restless legs syndrome. Periodic limb movement disorder is a sleep
disorder characterized by periodic limb movements that cause frequent arousals
and lead to insomnia or excessive daytime sleepiness. The results of PSG
studies from patients with severe restless legs syndrome often show prolonged
sleep latencies, decreased sleep efficiency, increased number of awakenings,
significant reductions in total sleep time, and decreased amounts of slow-wave
sleep. Patients with periodic limb movement disorder often have frequent
periodic limb movements that are associated with arousals and awakenings,
reduced total sleep time, and decreased sleep efficiency.

PSG is indicated when a diagnosis of periodic limb movement disorder is
considered because of complaints by the patient or an observer of repetitive
limb movements during sleep and frequent awakenings, fragmented sleep,
difficulty maintaining sleep, or excessive daytime sleepiness.

**Limitations**

  * 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 intended to be used for the diagnosis of narcolepsy, other respiratory disorders, impotence, parasomnia, restless legs syndrome, or periodic limb movements of sleep. HST is not intended to be used for patients with comorbidities: congestive heart failure, hypo-ventilation syndrome, moderate to severe pulmonary disease, or neuromuscular disease.
  * More than one Home Sleep Test (HST) to establish the diagnosis of OSA would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, a repeat Polysomnography (PSG) must meet the indications in the LCD and must be clearly supported in the medical record. Services performed in excess of established parameters, will be subject to prepay medical review. 
  * MLST is not routinely indicated for most patients with sleep apnea.
  * PSG is not routinely indicated to diagnose or treat restless legs syndrome, or for patients with epilepsy without specific complaints consistent with a sleep disorder.
  * Sleep studies and polysomnography are not indicated in the management of chronic insomnia. However, if sleep apnea is suspected as a contributing factor, then sleep studies and polysomnography may be considered.
  * Testing for Circadian rhythm sleep disorders is not covered. Circadian rhythm sleep disorders result from a mismatch between an individual's sleep pattern and the timing and amount of sleep that the person desires, needs, requires, or expects. The six types of rhythm disorders are time zone change (jet lag) disorder, shift work disorder, irregular sleep-wake patterns, delayed sleep-phase syndrome, advanced sleep-phase syndrome, and non-24-hour sleep-wake disorder.
  * There is limited durable medical equipment (DME) coverage for oral appliances for OSA. Polysomnography and/or Home Sleep Testing for evaluation or titration of a noncovered oral appliance are not covered services.
  * As noted, there is limited coverage of a custom fabricated mandibular advancement oral appliance used to treat obstructive sleep apnea (OSA) assuming all DME criteria and limitations are met. The utilization guidelines of HST/polysomnography noted above applicable to a patient utilizing a covered appliance in lieu of CPAP therapy would apply for reasonable and necessary services.
  * A single PSG is usually sufficient to titrate PAP therapy. Assuming an unattended portable monitoring or auto-titrating PAP device does not provide sufficient data, a single PSG is sufficient to titrate PAP therapy. Repeat PSG should not be routinely indicated for the assessment of treatment results in patients whose symptoms continue to be resolved with PAP treatment. Repeat PSG or PSG with CPAP titration may be indicated in the following circumstances: 
    1. After surgical treatment of patients with OSA, to ensure satisfactory response; or
    2. After surgical treatment of patients with OSA whose symptoms return despite a good initial response to treatment.
    3. After substantial weight loss has occurred in patients on PAP for treatment of OSA to ascertain whether PAP is still needed at the previously titrated pressure;
    4. After substantial weight gain has occurred in patients previously treated with PAP successfully, who are again symptomatic despite the continued use of PAP, to ascertain whether pressure adjustments are needed; or
    5. When clinical response is insufficient or when symptoms return despite a good initial response to treatment with PAP
    6. Initial CPAP was not tolerated and BPAP is to be used in lieu of CPAP

  * Ordinarily, a single PSG or HST can diagnose adult OSA. However, if the beneficiary's treating physician has good reason to believe that the result of an HST is insufficient in light of the beneficiary's clinical findings, a subsequent diagnostic PSG could be performed. Such retest decisions would be made on a case-by-case basis. The routine use of a two test routine (HST followed by PSG) to diagnose sleep apnea would not be considered reasonable and necessary. If more than one PSG or HST diagnostic testing session is claimed, persuasive medical evidence justifying the medical necessity for the additional tests will be required.
  * There are some situations in which it may be necessary for a provider to perform diagnostic and titration services on consecutive nights, IT would be unusual for a provider to do so routinely. Providers showing this utilization trend would be subject to medical review.
  * The center/laboratory must maintain and provide upon request sufficient documentation that the narcolepsy patient is severe enough to interfere with the patient's well-being and health before benefits are provided for diagnostic testing. 

As published in the CMS IOM Publication 100-08, _Medicare Program Integrity
Manual_ , Chapter 13, Section 13.5.4, an item or service may be covered by a
contractor LCD if it is reasonable and necessary under the Social Security Act
Section 1862 (a)(1)(A). Contractors shall determine and describe the
circumstances under which the item or service is considered reasonable and
necessary.

**Provider Qualifications**

For guidelines regarding supervision during performance of a procedure and
regarding studies performed in an Independent Diagnostic Testing Facility,
please refer to 42 CFR, Section 410.32 and Section 410.33 respectively.

The following provider qualification requirements must be met for the service
to be considered reasonable and necessary:

**Physicians:**

The raw data from all sleep tests must be reviewed and the tests must be
interpreted by either:

  1. A Diplomate of the American Board of Sleep Medicine (ABSM) **OR** Board of Medical Specialties (ABMS) **OR**
  2. A physician board certified in sleep medicine by a member board of the American Board of Medical Specialties (ABMS) **OR**
  3. An osteopathic physician board certified in sleep medicine by a member board of the American Osteopathic Association (AOA) **OR**
  4. An active physician staff member of an AASM accredited sleep center or sleep laboratory **OR**
  5. An active physician staff member of a Joint Commission accredited sleep laboratory **OR**
  6. An active physician staff member of a ACHC-accredited sleep laboratory **OR**
  7. A Diplomate of the American Board of Family Medicine (ABFM) with Certificate of Added Qualifications (CAQ) in Sleep Medicine.

**Sleep Technologist/Technician**

  * Sleep technicians or technologists attending PSG or sleep studies affiliated with HST must have appropriate personnel certification. Examples of certification in PSG and sleep technology for technologists are; 
    1. Registered Polysomnography Technologist (RPSGT)
    2. Registered Electroencephalographic technologist (R. EEG T.) - Polysomnography
    3. Certified Respiratory Therapist -Sleep Disorders Specialist (CRT-SDS)
    4. Registered Respiratory Therapist Sleep Disorders Specialist (RRT-SDS)
    5. American Board of Sleep Medicine Registered Sleep Technologist (RST)

Credentialing must be provided by nationally recognized credentialing
organizations such as:

  * Board of Registered Polysomnographic Technologists (BRPT) that provides (RPSGT) credential; **OR**
  * American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) that provides R. EEG T.) - Polysomnography credential; **OR**
  * Performed in a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM), or Accreditation Commission for Health Care (ACHC), or Joint Commission; **OR**
  * American Board of Sleep Medicine (ABSM) that provides credentialing in sleep technology; **OR**
  * National Board for Respiratory Care, Inc. (NBRC) that provides specialty examination for respiratory therapists performing sleep disorders testing and therapeutic intervention (CRT-SDS and RRT-SDS)

All technologists and technicians conducting sleep testing who are not
registered by the BRPT, ABRET, ABSM, NBRC or other accepted certification
body, must be affiliated with an AASM or ACHC accredited sleep facility or
Joint Commission accredited sleep facility (a Joint Commission accredited
sleep laboratory). Unregistered technologists and technicians must maintain
appropriate training and supervision, and, be supervised by a registered and
licensed technologist, where license is required by state law.

Technologist staffing must be adequate to address the workload of the sleep
facility and assure the safety of patients.

**Unattended Sleep Testing**

The technical component of HST and unattended sleep studies must be provided
by an accredited sleep center or laboratory as noted above 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 earlier. 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
patient's 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 above. Under this circumstance, the physician would
be the interpreter of the test and bill globally.

**Facility Accreditation:**

In order to perform the technical component (TC) of PSG and sleep testing
(including HST), the following must be met:

  * The sleep center or laboratory must maintain documentation on file that indicates it is accredited by the American Academy of Sleep Medicine (AASM), Accreditation Commission for Health Care (ACHC), or that it is accredited as a sleep laboratory by the Joint Commission. If the Joint Commission survey of the general hospital accreditation includes the hospital-based sleep lab, an additional accreditation is not needed. This documentation must be available on request. The AASM, ACHC, or Joint Commission accreditation applies to the hospital and freestanding facilities (including sleep clinics that are part of a physician's office, and all other non-hospital-based facilities where sleep studies are performed.