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Contractor Information

Contractor Name: First Coast Service Options, Inc. - Full list of policies of this Medicare Contractor Contractor Number: 09202 Contractor Type: MAC B

LCD Information

LCD ID Number: L33405 Status: A-Approved LCD Title: Polysomnography and Sleep Testing Geographic Jurisdiction: Puerto Rico Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 07/01/2020 Revision End Date: CMS National Coverage Policy: This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Polysomnography and Sleep Testing. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Polysomnography and Sleep Testing and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. INTERNET ONLY MANUAL (IOM) CITATIONS: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 50 Sleep Disorder Clinics Chapter 15, Section 70 Sleep Disorder Clinics and Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests 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) CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS) CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and necessary Provision in an LCD  Social Security Act (Title XVIII) Standard References: Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Federal Register References:  Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions and Part 410.33 Independent diagnostic testing facility.  Sorry, you need to login or register to view additional sections of this Medicare policy. *