Humana Facility Based Sleep Studies - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals. Type Title ID Number NCD Sleep Testing for Obstructive Sleep Apnea (OSA) 240.4.1 Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA Polysomnography and Other Sleep Studies L36839 A56903 Polysomnography and Other Sleep Studies L36902 A57049 Polysomnography and Other Sleep Studies L36861 A57697 Polysomnography and Other Sleep Studies Outpatient Sleep Studies Polysomnography Polysomnography and Sleep Testing L34040 A57698 L35050 A56923 L36593 A56995 L33405 A57496 Facility Based Sleep Studies Page: 2 of 5 J5, J8 - Wisconsin Physicians Service Insurance Corporation J15 - CGS Administrators, LLC (Part A/B MAC) JE - Noridian Healthcare Solutions, LLC JF - Noridian Healthcare Solutions, LLC JH, JL - Novitas Solutions, Inc. (Part A/B MAC) JJ, JM - Palmetto GBA (Part A/B MAC) JN - First Coast Service Options, Inc. (Part A/B MAC) IA, IN, KS, MI, MO, NE KY, OH CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX AL, GA, NC, SC, TN, VA, WV FL, PR, US VI Description A sleep study is a test that may be used to assist in the diagnosis of sleep disorders such as sleep apnea, narcolepsy or other nighttime behaviors. It can record a range of bodily functions during sleep such as: • Brain, heart and muscle activity • Eye movement • Heart monitoring • Oxygen saturation levels • Respiratory effort, rate and rhythm A sleep study may be performed in a sleep facility/laboratory or in the home. The scope of this medical coverage policy is limited to facility based testing. Polysomnogram (PSG) is a sleep study that is performed in a facility/laboratory setting and requires an overnight stay. PSG is designed to capture multiple sensory channels including blood pressure, brain waves, breathing patterns and heartbeat as an individual sleeps. It can also record eye and leg movements as well as muscle tension which can be useful in diagnosing parasomnias. A PSG performed at a facility will record a minimum of 12 channels which involves at least 22 wire attachments to the individual. Sensors that send electrical signals to a computer are placed on the chest, face, head and legs. This test is attended by a technologist and the results are evaluated by a qualified physician. A PSG may be performed in conjunction with a positive airway pressure (PAP) machine to determine the titration of oxygen flow. Facility Based Sleep Studies Page: 3 of 5 Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the criteria contained in the following: Polysomnography (PSG), Sleep Center The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage