Medicare contractor TrailBlazer Health Enterprises LLC issued a new polysomnography and sleep study Local Coverage Determination (LCD), outlining indications and limitations of coverage and/or medical necessity for polysomnography and sleep studies.
According to the policy, diagnostic tests are covered when:
• The clinic either is affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician.
• Patients are referred to the sleep disorder clinic by their attending physician and the clinic maintains a record of the attending physician’s orders.
• The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests.
Tests are covered for medical conditions listed in the “Indications” section of the LCD.
According to the policy, “Therapeutic services may be covered if they are standard and accepted services, are reasonable and necessary for the patient, are performed in a hospital inpatient or outpatient setting or freestanding facility, and are performed under the direct personal supervision of a physician.”
According to certification requirements documented in the policy, if the tests are done in a freestanding facility, defined as sleep clinics that are a part of a physician’s office, IDTFs, and all other non-hospital-based facilities where sleep studies are performed, “the facility must have on file, through TrailBlazer’s Provider Enrollment department, evidence that they are fully or provisionally certified by the American Academy of Sleep Medicine (AASM) as a sleep disorders center or as a laboratory for sleep-related breathing disorders.”