Description
This review will determine if polysomnography is reasonable and necessary for the patient’s condition based on the documentation in the medical record.
Affected Code(s)
95808, 95810, 95811
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
3. 42 CFR §405.929- Post-Payment Review
4. 42CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
8. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.4.1- Sleep Testing for Obstructive Sleep Apnea (OSA)
9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §70.B- Medical Conditions for Which Testing is Covered ; §70.C- Polysomnography for Chronic Insomnia Is Not Covered
10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6
12. CGS Administrators, LLC, LCD L36902- Polysomnography and Other Sleep Studies; Effective 3/6/2017; Revised 03/07/2024
13. CGS Administrators, LLC, LCA A57049- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 9/26/2019; Revised 03/07/2024
14. First Coast Service Options, Inc., LCD L33405- Polysomnography and Sleep Testing; Effective 10/01/2015; Revised 7/01/2020
15. First Coast Service Options, Inc., LCA A57496- Billing and Coding: Polysomnography and Sleep Testing; Effective 10/03/2018; Revised 07/07/2021
16. Noridian Healthcare Solutions, LLC, LCD L34040- Polysomnography and Other Sleep Studies; Effective 10/01/2015; Revised 12/01/2019
17. Noridian Healthcare Solutions, LLC, LCD L36861- Polysomnography and Other Sleep Studies; Effective 06/05/2017; Revised 12/01/2019
18. Noridian Healthcare Solutions, LLC, LCA A57697- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 12/01/2019
19. Noridian Healthcare Solutions, LLC, LCA A57698- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 12/01/2019
20. Novitas Solutions, Inc., LCD L35050- Outpatient Sleep Studies; Effective 10/01/2015; Revised 01/01/2021
21. Novitas Solutions, Inc., LCA A56923- Billing and Coding: Outpatient Sleep Studies; Effective 9/12/2019; Revised 01/01/2023
22. Palmetto GBA, LCD L36593- Polysomnography; Effective 6/13/2016; Revised 03/16/2023
23. Palmetto GBA, LCA A56995- Billing and Coding: Polysomnography; Effective 9/12/2019; Revised 03/07/2024
24. WPS, LCD L36839- Polysomnography and Other Sleep Studies; Effective 2/16/2017; Revision effective 07/27/2023
25. WPS, LCA A56903- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 8/29/2019; Revised 07/27/2023
26. National Government Services, Inc., LCA A53019- Polysomnography and Sleep Studies- Medical Policy Article; Effective 10/01/2015; Revised 10/31/2019
27. AMA CPT Codebook