Page 93 - Medicare Benefit Policy Manual

• Patients are referred to the sleep disorder clinic by their attending physicians, and
the clinic maintains a record of the attending physician’s orders; and

• The need for diagnostic testing is confirmed by medical evidence, e.g., physician
examinations and laboratory tests.

Diagnostic testing that is duplicative of previous testing done by the attending physician
to the extent the results are still pertinent is not covered because it is not reasonable and
necessary under §1862(a)(1)(A) of the Act.

B. 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. Most of the patients who undergo the diagnostic testing are
not considered inpatients, although they may come to the facility in the evening for
testing and then leave after testing is over. The overnight stay is considered an integral
part of these tests.

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 three sleep naps. If more than
three sleep naps are claimed, the A/B MAC (B) will require persuasive medical evidence
justifying the medical necessity for the additional test(s). It will use HCPCS procedure
codes 95828 and 95805.

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. It will use HCPCS procedure codes 95807,
95810, and 95822.

3. Impotence - Diagnostic nocturnal penile tumescence testing may be covered, under
limited circumstances, to determine whether erectile impotence in men is organic or
psychogenic. Although impotence is not a sleep disorder, the nature of the testing
requires that it be performed during sleep. The tests ordinarily are covered only where
necessary to confirm the treatment to be given (surgical, medical, or psychotherapeutic).
Ordinarily, a diagnosis may be determined by two nights of diagnostic testing. If more
than two nights of testing are claimed, the A/B MAC (B) will require persuasive medical