LCD Reference Article Response To Comments Article

Response to Comments: Polysomnography and Other Sleep Studies

A60188

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Source Article ID
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Article ID
A60188
Original ICD-9 Article ID
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Article Title
Response to Comments: Polysomnography and Other Sleep Studies
Article Type
Response to Comments
Original Effective Date
07/20/2025
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The Proposed Polysomnography and Other Sleep Studies Local Coverage Determination (LCD) was posted for comment by Noridian Healthcare Solutions (NHS) on July 18, 2024, through September 1, 2024. All comments received within the Open Comment Period have been reviewed and responded to below.

Response To Comments

Number Comment Response
1

We recommend the final policy identify a threshold for which oximetry results service as justification for a medically necessary polysomnography (PSG) with the following recommendations:

  • Oxygen Desaturation Index ODI >10 (associated with risk of moderate to severe OSA).
  • Cumulative time spent <89% is > 5 minutes (sleep associated hypoxemia) without any existing cardiopulmonary disease to explain the hypoxemia.

Additionally, the current draft policy limits reimbursement for actigraphy. Actigraphy aids in diagnosing certain sleep disorders and monitoring the treatment progress of people who have been diagnosed with certain sleep disorders. We believe actigraphy is reasonable and necessary under this policy when evaluating a patient for a CNS hypersomnia to help eliminate other potential causes of excessive sleepiness such as insufficient sleep and/or circadian rhythm disorder. We routinely perform actigraphy prior to conducting a polysomnogram followed by a multiple sleep latency test (MSLT).

The final policy should provide greater clarity on symptoms considered consistent with sleep apnea. We believe the following signs and symptoms to be indications of coverage and seek the addition of the below language to the policy.

"Sleep history and symptoms include, but not limited to…"

  • Daytime sleepiness
  • Snoring
  • Observed episodes of stopped breathing during sleep
  • Waking during sleep and gasping or choking
  • Awakening during sleep with a dry mouth or sore throat
  • Frequent headaches

We request that Noridian support coverage of PSG for REM behavior sleep disorder (RBD) regardless of ruling out seizure and even if patient has not injured self/others.

This draft policy should also allow for coverage of a repeat polysomnography if a prior study was analyzed using the recommended 1A scoring criteria (i.e., ≥ 3 % oxygen desaturation) as outlined in the AASM Manual for Scoring of Sleep and Associated Events.

No data receives to support the request- Just statement of CMS criteria for Respiratory Assist device. This policy is about Polysomnography and other sleep studies and not other individual tests included in various types of sleep testing.

Actigraphy is not considered under LCD L36861 except when ordered as part of a Type IV sleep device. It is not considered separately and not part of this policy.

This LCD assumes that the ordering provider will list appropriate signs and symptoms to justify the testing ordered or the test will not be considered reasonable and necessary. These are listed under conditions for testing. No data receives to support the request.

No full copies of articles were furnished as required for such changes.

It is felt by this contractor that examination of the prior study should be performed on the patient using current 4% criteria if available prior on the original test.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L36861 - Polysomnography and Other Sleep Studies
Related National Coverage Documents
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Updated On Effective Dates Status
05/27/2025 07/20/2025 - N/A Currently in Effect You are here

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