Medicare Policies

General Information

Medicare is a single-payer, national insurance program administered by the U.S. federal government for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease.

Medicare has four parts: Part A is hospital/hospice insurance, Part B is medical insurance, Part C includes health plans branded as Medicare Advantage and Part D covers many prescription drugs. Providers working in hospital settings, including critical access hospitals and skilled nursing facilities, are considered Medicare Part A providers. Providers working in outpatient clinics and settings are considered Medicare Part B providers. The Medicare Provider-Supplier Enrollment webpage provides additional details on how to enroll as a Medicare provider or supplier.

The Centers for Medicare and Medicaid Services (CMS) establishes national coverage determinations (NCDs) for items and services furnished through Medicare.

CMS also awards geographic jurisdictions to private health care insurers called Medicare Administrative Contractors (MACs) to develop policies and process claims. The policies that MACs develop are called Local Coverage Determinations (LCDs) and these may vary from region to region. An LCD can never contradict an NCD, but it can expand on coverage policies for a particular region.

A/B MACs process Medicare Part A and Medicare Part B claims for a defined geographic area or “jurisdiction.” Part A and B providers are required to adhere to the LCD(s) that is in place for their particular jurisdiction.

Search for a Medicare Policy

Go to the CMS Centers for Medicare & Medicaid Services website to search the Medicare Coverage Database. The Medicare Coverage Database includes documents such as articles and policies related to all Medicare programs including but not limited to Part B coverage and DME. Use the advanced search feature to perform a search. Several frequently accessed sleep related policies can be found here.

Medicare Administrative Contractors and Jurisdictions

Find contact information for all MACs and Medical Directors using the CMS Contact List.

National Coverage Determinations

Sleep Testing for Obstructive Sleep Apnea (OSA) (240.4.1)
Effective Date: March 3, 2009

Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (240.4)
Effective Date: March 13, 2008

Medicare Part A/B – Local Coverage Determinations and Articles

Polysomnography, Other Sleep Studies, and Surgical Treatments of OSA

The following tables list all sleep policy LCDs organized by MAC.

Hypoglossal Nerve Stimulation for the Treatment of OSA

DME Medicare Administrative Contractors

DME – Local Coverage Determinations

The following chart lists all of the LCDs and Local Coverage Articles for positive airway pressure devices, oral appliances, and respiratory assist devices.

DME MAC– Resources

DME MACs have developed Dear Clinician letters, checklists, and other resources that highlight documentation and medical review requirements for sleep studies and scoring. Standard documentation requirements for all claims submitted to DME MACs can be found here.

Please note that part or all of these policies may be revised at the discretion of CMS at various times throughout the year. Although the AASM will update these resources as we become aware of changes, it is the responsibility of the individual sleep medicine facility or provider using this information to confirm the information is accurate and up-to-date with the specific Medicare Administrative Contractor serving their region.