Page 94 - Medicare Benefit Policy Manual

evidence justifying the medical necessity for the additional tests. It will have its medical
staff review questionable cases to ensure that the tests are reasonable and necessary for
the individual. It will use HCPCS procedure code 54250. (See the Medicare National
Coverage Determinations Manual, Chapter 1, for policy on coverage of diagnosis and
treatment of impotence.)

4. Parasomnia - Parasomnias are a group of conditions that represent undesirable or
unpleasant occurrences during sleep. Behavior during these times can often lead to
damage to the surroundings and injury to the patient or to others. Parasomnia may
include conditions such as sleepwalking, sleep terrors, and rapid eye movement (REM)
sleep behavior disorders. In many of these cases, the nature of these conditions may be
established by careful clinical evaluation. Suspected seizure disorders as possible cause
of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG
studies. In cases where seizure disorders have been ruled out and in cases that present a
history of repeated violent or injurious episodes during sleep, polysomnography may be
useful in providing a diagnostic classification or prognosis. The A/B MAC (B) must use
HCPCS procedure codes 95807, 95810, and/or 95822.

C. Polysomnography for Chronic Insomnia Is Not Covered.

Evidence at the present time is not convincing that polysomnography in a sleep disorder
clinic for chronic insomnia provides definitive diagnostic data or that such information is
useful in patient treatment or is associated with improved clinical outcome. The use of
polysomnography for diagnosis of patients with chronic insomnia is not covered under
Medicare because it is not reasonable and necessary under §1862(a)(1)(A) of the Act.

D. Coverage of Therapeutic Services.
Sleep disorder clinics may at times render therapeutic as well as diagnostic services.
Therapeutic services may be covered in a hospital outpatient setting or in a freestanding
facility provided they meet the pertinent requirements for the particular type of services
and are reasonable and necessary for the patient, and are performed under the direct
supervision of a physician.

80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and
Other Diagnostic Tests
(Rev. 11901; Issued: 03-16-23; Effective: 01-01-21; Implementation: 05-17-23)

This section describes the levels of physician supervision required for furnishing the
technical component of diagnostic tests for a Medicare beneficiary who is not a hospital
inpatient. For hospital outpatient diagnostic services, the supervision levels assigned to
each CPT or Level II HCPCS code in the Medicare Physician Fee Schedule Relative
Value File that is updated quarterly, apply as described below. For more information, see
Chapter 6 (Hospital Services Covered Under Part B), §20.4 (Outpatient Diagnostic
Services).