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LCD ID Number: L34040 Status: A-Approved
LCD Title: Polysomnography and Other Sleep Studies
Geographic Jurisdiction: Arizona Other Jurisdictions
Original Determination Effective Date:
10/01/2015
Original Determination Ending Date:
Revision Effective Date:
12/01/2019
Revision End Date:
CMS National Coverage Policy:
When the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
CMS Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1
CMS Publication 100-03 Medicare National Coverage Determination (NCD) Manual) Chapter 1,
Section 240.4.1 Sleep Testing for Obstructive sleep Apnea (OSA) (Effective March 3, 2009) and
Section 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective March 13, 2008)
CMS Publication 100-02 Medicare Benefit Policy Chapter 6, Section 50 Sleep Disorder Clinics
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70 Sleep Disorder Clinics
CMS Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N)
CMS Decision Memo for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea (CAG-00093R2)
Italicized font -represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.
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