LCD ID Number: L35050 Status: A-Approved
LCD Title: Outpatient Sleep Studies
Geographic Jurisdiction: Pennsylvania Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
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 outpatient sleep services. 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 outpatient sleep services 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.
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
- Chapter 15, Section 70 Sleep Disorder Clinics
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
- Chapter 1, Part 4, Section 230.4 Diagnosis and Treatment of Impotence, Section 240.4 Continuous Positive Airway Pressure (CPAP) Therapy 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
Change Request References:
- Change Request 6534, Transmittal 103, July 10, 2009 Sleep Testing for Obstructive Sleep Apnea
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
Federal Register References:
- CFR, Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests
- Federal Register, Vol. 65, No. 68, April 7, 2000, page 18434 is the Medicare Program Prospective Payment System for Hospital Outpatient Services Final Rule
- Coverage Decision Memorandum for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R2), March 13, 2008
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