Medical Policy Original Effective Date:01/23/2019

Transcription

1 Page 1 of 17 Disclaimer Description Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in these criteria. This MPM may or may not require Prior Authorization. Log on to Pres Online to verify and/or submit a request: Sleep-disordered breathing is a common disorder affecting both children and adults. Obstructive sleep apnea (OSA) is the collapse of the oropharyngeal walls and the obstruction of airflow occurring during sleep. The sleep tests are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA Diagnostic tests for OSA is determined by the results four types of sleep tests. Type I: full attended polysomnography (greater than or equal to 7 channels) in a laboratory setting Type II: full unattended polysomnography (greater than or equal to 7 channels) Type III: limited channel devices (usually using 4 7 channels) Type IV: sleep testing devices 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 sleep lab facility or attended in a sleep lab facility. Sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial 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. Repeat polysomnography or sleep testing for diagnosing sleep apnea OR initial polysomnography and MSLT fail to identify narcolepsy. Documentation must justify the medical

2 Page 2 of 17 necessity for the repeated test. Repeat polysomnography sleep testing may be specified: if the first study is technically inadequate due to equipment failure; if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; if the results were inconclusive or ambiguous; OR if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. Total Sleep time - Continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours, (with at least 120 minutes of sleep for the test to be valid), which includes physician review, interpretation and report. 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). Certification/Accreditation Documentation Documentation Requirements: 1. All documentation must support the medical necessity of the service and maintained in the patient's medical record and made available upon request. The record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). Legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient must be included. 2. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 3. All centers billing sleep studies must maintain proper certification/accreditation documentation as defined in the Indications and Limitations, which include: Accreditation of sleep centers to include AASM, Joint Commission, or ACHC 4. All Sleep Studies, whether in a facility based, or OCST shall be interpreted by appropriate physician with

3 Page 3 of 17 training in this area. Acceptable Board Certifications include physicians need to be board certified OR board eligible with a certification in Sleep Medicine 5. Appropriate technical personnel credentialing includes: Board of Registered Polysomnographic Technologist (BRPT): o Certified Polysomnographic Technician (CPSGT), o Registered Polysomnography Technologist (RPSGT), and National Board of Respiratory Care (NBRC): o Certified Respiratory Therapist-Sleep Disorders Specialist (CRT-SDS) o Registered Respiratory Therapist Sleep Disorders Specialist (RRT-SDS), and American Board of Sleep Medicine (ABSM) o Registered Sleep Technologist (RST) 6. The patient is to be evaluated by a physician prior to ordering of test. This physician is not required to be a Sleep Specialist when billing for an OCST. When billing for a sleep disorder test, the ordering physician's national identification number must be indicated on the claim form and the order kept on record. 7. The center/laboratory must maintain and provide upon request sufficient documentation that the narcolepsy patient is severe enough to interfere with the patients' well-being and health before benefits are provided for diagnostic testing. 8. If more than two nights of testing are claimed, medical documentation must justify the medical necessity for the additional test(s) should it be requested. 9. Studies may be performed in a freestanding center that is a direct extension of a physician's office or in an Independent Diagnostic Testing Facility (IDTF) with restrictions as indicated in LCD L Sleep studies performed in the home shall only be

4 Page 4 of 17 covered under special circumstances described in LCD L35050 under "Out of Center Sleep Testing (OCST)." All home sleep studies, to be covered, must be under the supervision of the hospital based sleep lab, a sleep clinic that is a direct extension of the physician's office, an IDTF, or entity accredited by AASM as an OCST entity. Coverage Determination Use the Prior Authorization/Benefit Certification Guide to determine when a prior authorization/benefit certification is required PHP follows (LCD L35050) guidelines for Outpatient Sleep Studies Polysomnography- sleep staging.is defined to include, but is not limited to the following: A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, or masseter regions Rhythm electrocardiogram (ECG) with two or three chest leads Nasal or oral airflow via mercury switches or by direct observation Ventilation and respiratory effort by chest-wall and abdominal movement measured using strain gauges, piezoelectric belts, inductive plethysmography, impedance or inductance pneumography, endoesophageal pressure, or by intercostal EMG Gas exchange (oxygen saturation [SpO2]) by oximetry, transcutaneous monitoring, or end-tidal gas analysis Extremity muscle activity, motor activity-movement using EMG

5 Page 5 of 17 Body positions via mercury switches or by direct observation Recordings of vibration (frequency or volume) may be recorded Multiple sleep Latency testing (MSLT) Facility based study to determine the tendency of the patient to fall asleep. This test is primarily used to confirm the suspected diagnosis of narcolepsy. (The MSLT may be indicated as part of the evaluation of patients with suspected idiopathic hypersomnia to help differentiate idiopathic hypersomnia from narcolepsy). To insure validity, proper interpretation of the MSLT can only be made following a polysomnography performed on the preceding night. Sleep studies performed in the home shall only be covered under special circumstances listed in L35050 under "Out of Center Sleep Testing (OCST)." All home sleep studies, to be covered, must be under the supervision of the hospital based sleep lab, a sleep clinic that is a direct extension of the physician's office, an IDTF, or entity accredited by AASM as an OCST entity. Medical Conditions for Which Testing is Covered Diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed below. 1. Narcolepsy - This term refers to a syndrome that is characterized by abnormal sleep tendencies, e.g., excessive daytime sleepiness or disturbed nocturnal sleep. Related diagnostic testing is covered if the patient has inappropriate sleep episodes or attacks (e.g., while driving, in the middle of a meal, in the middle of a conversation), amnesiac episodes, or continuous disabling drowsiness. The sleep disorder clinic must submit documentation that this condition is severe enough to interfere with the patient s well-being and health before Medicare benefits may be provided for diagnostic testing. Ordinarily, a diagnosis of narcolepsy can be confirmed by a MSLT Study. If more than one MSLT study is claimed, persuasive medical evidence justifying the medical necessity for the additional test(s) will be required. The diagnosis of narcolepsy is usually confirmed by an

6 Page 6 of 17 overnight sleep study (polysomnography) followed by a multiple sleep latency test (MSLT). ALL of following measurements are normally required to diagnose narcolepsy: Polysomnographic assessment of the quality and quantity of nighttime sleep; Determination of the latency of the first REM episode; MSLT; and The presence of REM-sleep episodes. Initial polysomnography and MSLT occasionally fail to identify narcolepsy, (see above Repeat polysomnography or sleep testing). 2. Sleep Apnea- This is a potentially lethal condition where the patient stops breathing during sleep. Three types of sleep apnea have been described (central, obstructive, and mixed). The nature of the apnea episodes can be documented by appropriate diagnostic testing. Ordinarily, a single polysomnogram and electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed the A/B MAC (B) will require persuasive medical evidence justifying the medical necessity for the additional tests Testing by type III or IV devices can also be covered under special circumstances. See definitions of home sleeping testing (HST) section in LCD L Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30 percent reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4 percent oxygen desaturation Sleep apnea may be due to an occlusion of the airway (obstructive apnea), absence of respiratory effort (central sleep apnea) or a combination of these factors (mixed sleep apnea). Obstructive sleep apnea (OSA) may be caused by one of the following:

7 Page 7 of 17 Reduced upper airway caliber due to obesity; Adenotonsillar hypertrophy; Mandibular deficiency; Macroglossia; Upper airway tumor; Excessive pressure across the collapsible segment of the upper airway; Activity of the muscles of the upper airway insufficient to maintain patency. 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. **The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 30 episodes recorded by polysomnography using actual recorded hours of sleep without symptoms and 10 episodes with symptoms above. **The RDI is defined as the number of apneas and hypopneas per hour of recording time. Continuous Positive Airway Pressure (CPAP) is a noninvasive technique for providing single 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 obstructive sleep apnea (OSA). The use of CPAP devices is covered when ordered and prescribed by the licensed treating physician to be used in adult patients with OSA if either of the AHI/RDI criteria mentioned above are met. See MPM 4.3 for CPAP device criteria

8 Page 8 of 17 For DME Positive Airway Pressure Devices for the treatment of Obstructive Sleep Apnea, see MPM 4.3 The polysomnography Type II, III or Type IV devices as defined above must be performed in a facility-based sleep study laboratory or by portable monitoring (including in other parts of a facility, out of facility, or at home testing) under the restrictions listed above and with the credentialing requirements being met. Initial claims must be supported by medical documentation (separate documentation where electronic billing is used) with documentation of medical necessity. The claim must also certify that the documentation supporting a diagnosis of OSA (described above) is available. For patients with severe and unambiguous obstructive sleep apnea, the initiation of treatment with nasal CPAP may be incorporated into the diagnostic study night. This is called a "split-night" study (initial diagnostic polysomnogram followed by CPAP titration during polysomnography on the same night). A split night study is an overnight polysomnogram in which the patient spends the first half of the night being monitored for sleep apnea. In the event the study shows severe enough disease to merit treatment with CPAP (refer to the Medicare DME LCD on CPAP requirements), the technologist will place the patient on CPAP and will adjust the pressure on the CPAP to treat the underlying sleep apnea. This approach may be an alternative to one full night of diagnostic polysomnography followed by a second night of titration as long as: CPAP titration is carried out for more than 3 hours; and Polysomnography documents that CPAP eliminates or nearly eliminates the respiratory events during REM and NREM sleep. Repeat polysomnography or sleep testing for diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. For repeat polysomnography/sleep testing see above. Follow-up polysomnography or sleep studies are not routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP treatment.

9 Page 9 of 17 Follow-up polysomnography studies may be indicated, however, for the following conditions: After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure; After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; or When clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP. 3. Parasomnia- Parasomnias are a group of conditions that represent undesirable or unpleasant occurrences during sleep. Behavior during these times can often lead to damage to the surroundings and injury to the patient or to others. Parasomnia may include conditions such as sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorders. In many of these cases, the nature of these conditions may be established by careful clinical evaluation. Suspected seizure disorders as possible cause of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis. These studies shall not be performed in the home. Normally, a clinical history, neurologic examination, and routine EEG obtained while the patient is awake and asleep are often sufficient to establish the diagnosis and permit the appropriate treatment of sleep-related epilepsy. In addition, common, uncomplicated, noninjurious parasomnias, such as typical disorders of arousal, nightmares, enuresis, somniloquy, and bruxism can usually be diagnosed by clinical evaluation alone. Polysomnography is indicated to provide a diagnostic classification or prognosis when both of the following exist:

10 Page 10 of 17 When the clinical evaluation and results of standard EEG have ruled out a seizure disorder; and In cases that present a history of episodes during sleep that result in harm to the patient or others. When polysomnography is performed for the diagnosis of parasomnias, the following measurements are obtained: Sleep-scoring channels (EEG, EOG, chin EMG); EEG using an expanded bilateral montage; EMG for body movements; Audiovisual recording; and Documented technologist observations. Coverage of Therapeutic Services. Sleep disorder clinics may at times render therapeutic as well as diagnostic services. Therapeutic services may be covered in a hospital outpatient setting or in a freestanding facility provided they meet the pertinent requirements for the particular type of services and are reasonable and necessary for the patient, and are performed under the direct supervision of a physician. Exclusion Polysomnography for Chronic Insomnia Is Not Covered. Evidence at the present time is not convincing that polysomnography in a sleep disorder clinic for chronic insomnia provides definitive diagnostic data or that such information is useful in patient treatment or is associated with improved clinical outcome. The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under Medicare because it is not reasonable and necessary under 1862(a)(1)(A) of the Act. Repeat of previous sleep test: Diagnostic testing that is duplicative of previous sleep testing done by the attending physician to the extent that the previous results are still pertinent is not covered, because it is not reasonable and necessary if there have been no

11 Page 11 of 17 significant clinical changes in the patient's medical history since the previous study. Polysomnography or sleep studies, and MSLT are not covered in the following situations: For the diagnosis of patients with chronic insomnia; To preoperatively evaluate a patient for laser-assisted uvulopalatopharyngoplasty without clinical evidence that obstructive sleep apnea is suspected; To diagnose chronic lung disease (nocturnal hypoxemia in patients with chronic, obstructive, restrictive or reactive lung disease is usually adequately evaluated by oximetry; however, if the patient's sign/symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography may be considered medically necessary); In cases where seizure disorders have not been ruled out; In cases of typical, uncomplicated and non-injurious parasomnias when the diagnosis is clearly delineated; For patients with epilepsy who have no specific complaints consistent with a sleep disorder; For patients with symptoms suggestive of periodic limb movement disorder or restless leg syndrome unless symptoms are suspected of being related to a covered indication; For the diagnosis of insomnia related to depression; For the diagnosis of circadian rhythm sleep disorders (i.e., rapid time-zone change [jet lag], shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24 hour sleep/wake disorder). Inappropriate use of OCST for diagnosis of OSA OCST is not suitable for diagnosing OSA in patients with significant comorbid medical conditions or comorbid sleep disorders that may degrade the accuracy of Portable Monitoring, including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure.

12 Page 12 of 17 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. Coding The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list. Current Procedural Terminology (CPT) Codes CPT Description Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis, and sleep time Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

13 Page 13 of 17 CPT G0398 G0399 G0400 Description Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist Home sleep study test (HST) with type II portable Home sleep study test (HST) with type III portable Home sleep study test (HST) with type IV portable monitor, unattended; minimum of 3 channels ICD-10 Diagnosis Codes ICD-10 CODE Diagnosis for CPT code E66.2 Morbid (severe) obesity with alveolar hypoventilation F Opioid abuse with opioid-induced sleep disorder F Opioid dependence with opioid-induced sleep disorder F Opioid use, unspecified with opioid-induced sleep disorder F Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder F Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder F Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep disorder F Cocaine abuse with cocaine-induced sleep disorder F Cocaine dependence with cocaine-induced sleep disorder F Cocaine use, unspecified with cocaine-induced sleep disorder F Other stimulant abuse with stimulant-induced sleep disorder F Other stimulant dependence with stimulant-induced sleep disorder F Other stimulant use, unspecified with stimulant-induced sleep disorder F Other psychoactive substance abuse with psychoactive substance-induced sleep disorder F Other psychoactive substance dependence with psychoactive substance-induced sleep disorder

14 Page 14 of 17 F Other psychoactive substance use, unspecified with psychoactive substance-induced sleep disorder F51.13 Hypersomnia due to other mental disorder F51.8 Other sleep disorders not due to a substance or known physiological condition G47.10 Hypersomnia, unspecified G47.11 Idiopathic hypersomnia with long sleep time G47.12 Idiopathic hypersomnia without long sleep time G47.13 Recurrent hypersomnia G47.14 Hypersomnia due to medical condition (code also associated medical condition) G47.19 Other hypersomnia G47.21 Circadian rhythm sleep disorder, delayed sleep phase type G47.22 Circadian rhythm sleep disorder, advanced sleep phase type G47.23 Circadian rhythm sleep disorder, irregular sleep wake type G47.24 Circadian rhythm sleep disorder, free running type G47.25 Circadian rhythm sleep disorder, jet lag type G47.26 Circadian rhythm sleep disorder, shift work type G47.27 Circadian rhythm sleep disorder in conditions classified elsewhere G47.29 Other circadian rhythm sleep disorder G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.39 Other sleep apnea G Narcolepsy with cataplexy G Narcolepsy without cataplexy G G Narcolepsy in conditions classified elsewhere with cataplexy (code first underlying condition) Narcolepsy in conditions classified elsewhere without cataplexy (code first underlying condition) G47.52 REM sleep behavior disorder

15 Page 15 of 17 G47.53 Recurrent isolated sleep paralysis ICD-10 CODE Diagnosis coverage for CPT codes 95800, 95801, 95806, 95808, 95810, 95811, G0398, G0399, and G0400 E66.2 Morbid (severe) obesity with alveolar hypoventilation F Alcohol abuse with alcohol-induced sleep disorder F Alcohol dependence with alcohol-induced sleep disorder F Alcohol use, unspecified with alcohol-induced sleep disorder F Opioid abuse with opioid-induced sleep disorder F Opioid dependence with opioid-induced sleep disorder F Opioid use, unspecified with opioid-induced sleep disorder F Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder F Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder F Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep disorder F Cocaine abuse with cocaine-induced sleep disorder F Cocaine dependence with cocaine-induced sleep disorder F Cocaine use, unspecified with cocaine-induced sleep disorder F Other stimulant abuse with stimulant-induced sleep disorder F Other stimulant dependence with stimulant-induced sleep disorder F Other stimulant use, unspecified with stimulant-induced sleep disorder F Other psychoactive substance abuse with psychoactive substanceinduced sleep disorder F19.21 Other psychoactive substance dependence, in remission F Other psychoactive substance dependence with psychoactive substance-induced sleep disorder F Other psychoactive substance use, unspecified with psychoactive substance-induced sleep disorder F51.01 Primary insomnia F51.02 Adjustment insomnia F51.03 Paradoxical insomnia F51.09 Other insomnia not due to a substance or known physiological condition F51.11 Primary hypersomnia F51.12 Insufficient sleep syndrome F51.19 Other hypersomnia not due to a substance or known physiological condition F51.3 Sleepwalking [somnambulism] F51.4 Sleep terrors [night terrors] F51.5 Nightmare disorder

16 Page 16 of 17 ICD-10 CODE F51.8 Diagnosis coverage for CPT codes 95800, 95801, 95806, 95808, 95810, 95811, G0398, G0399, and G0400 Other sleep disorders not due to a substance or known physiological condition G47.10 Hypersomnia, unspecified G47.11 Idiopathic hypersomnia with long sleep time G47.12 Idiopathic hypersomnia without long sleep time G47.13 Recurrent hypersomnia G47.19 Other hypersomnia G47.20 Circadian rhythm sleep disorder, unspecified type G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.32 High altitude periodic breathing G47.33 Obstructive sleep apnea (adult) (pediatric) G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation G47.35 Congenital central alveolar hypoventilation syndrome G47.36 Sleep related hypoventilation in conditions classified elsewhere G47.39 Other sleep apnea G Narcolepsy with cataplexy G Narcolepsy without cataplexy G Narcolepsy in conditions classified elsewhere with cataplexy G Narcolepsy in conditions classified elsewhere without cataplexy G47.50 Parasomnia, unspecified G47.51 Confusional arousals G47.54 Parasomnia in conditions classified elsewhere G47.59 Other parasomnia G47.61 Periodic limb movement disorder G47.69 Other sleep related movement disorders G47.8 Other sleep disorders N52.01* N52.02* N52.03* Erectile dysfunction due to arterial insufficiency Corporo-venous occlusive erectile dysfunction Combined arterial insufficiency and corporo-venous occlusive erectile dysfunction References 1. CMS, Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, 70 Sleep Disorder Clinics, Revision #241 on For additional information on MSLT, Impotence, Parasomnia, Chronic Insomnia and Coverage of Therapeutic Services. Accessed 10/29/2018

17 Page 17 of CMS, LCD L35050, Outpatient Sleep Studies, Revision number 4, Revision Date 03/08/2018. Assessed 10/29/ CMS, Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Section ) Coverage Determinations, Revision 198, For additional info on Sleep Apnea. Accessed 10/30/ CMS, NCD for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (240.4), Effective Date 03/13/2008. Accessed 10/30/2018 Approval Signatures Clinical Quality Committee: Norman White MD Medical Directory: David Yu MD Approval Dates 01/23/2019 Publications History Approved by CQUMC This is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: Click here for Medical Polices