Coverage Limitations for Sleep Disorder Testing
Diagnostic testing that is duplicative of previous sleep testing, to the extent the results are still pertinent, is not covered if there have been no significant clinical changes in medical history since the previous study.
Polysomnography, cardiorespiratory sleep studies, and MSLTs are not covered in the following situations:
- For the diagnosis of patients with chronic insomnia;
- To preoperatively evaluate a patient undergoing a laser assisted uvulopalato-pharyngoplasty 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 symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography is considered medically necessary);
- In cases of typical, uncomplicated, and noninjurious 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 the periodic limb movement disorder or restless leg syndrome unless symptoms are suspected to be related to a covered indication.
CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:
- PSG performed in a sleep laboratory; or
- unattended home sleep monitoring device of type II; or
- unattended home sleep monitoring device of type III; or
- unattended home sleep monitoring device of type IV, measuring at least 3 channels
Screening tests, in the absence of associated signs, symptoms or complaints will be denied.
this says Screening tests, in the absence of associated signs, symptoms or complaints will be denied.
Does that mean that the sleep lab needs to obtain a copy of the medical records from the referring doctor to show documented signs and symptoms of OSA? In an audit, would those records be needed? If the lab doesn't provide those records in an audit would payment for the sleep study be denied/recouped?