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.
Medicare Administrative Contractors and Jurisdictions
MAC Jurisdiction | States in which Part A & Part B Claims are Processed | MAC |
---|---|---|
5 | Iowa, Kansas, Missouri, Nebraska | Wisconsin Physicians Service Insurance Corporation |
6 | Illinois, Minnesota, Wisconsin | National Government Services, Inc. |
8 | Indiana, Michigan | Wisconsin Physicians Service Insurance Corporation |
15 | Kentucky, Ohio | CGS Administrators, LLC |
E | California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands | Noridian Healthcare Solutions, LLC |
F | Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming | Noridian Healthcare Solutions, LLC |
H | Arkansas, Colorado, New Mexico, Oklahoma, Texas, Louisiana, Mississippi | Novitas Solutions, Inc. |
J | Alabama, Georgia, Tennessee | Palmetto GBA, LLC |
K | Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont | National Government Services, Inc. |
L | Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania (includes Part B for counties of Arlington and Fairfax in Virginia and the city of Alexandria, VA) | Novitas Solutions, Inc. |
M | North Carolina, South Carolina, Virginia, West Virginia (excludes Part B for the counties of Arlington and Fairfax in Virginia and the city of Alexandria, VA) | Palmetto GBA, LLC |
N | Florida, Puerto Rico, U.S. Virgin Islands | First Coast Service Options, Inc. |
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.
MAC | LCD | Local Coverage Article |
---|---|---|
Wisconsin Physicians Service Insurance Corporation
Jurisdiction 5, 8 |
POLYSOMNOGRAPHY and Other Sleep Studies L36839
Effective Date: July 29, 2021 |
POLYSOMNOGRAPHY and Other Sleep Studies A56903
Effective Date: September 30, 2021 |
Wisconsin Physicians Service Insurance Corporation
Jurisdiction 5, 8 |
Surgical Treatment of Obstructive Sleep Apnea (OSA) L34526
Effective Date: July 29, 2021 |
Surgical Treatment of Obstructive Sleep Apnea (OSA) A56905
Effective Date: July 29, 2021 |
CGS Administrators, LLC
Jurisdiction 15 |
POLYSOMNOGRAPHY and Other Sleep Studies L36902
Effective Date: February 3, 2022 |
POLYSOMNOGRAPHY and Other Sleep Studies A57049
Effective Date: February 3, 2022 |
Noridian Healthcare Solutions, LLC
Jurisdiction E |
POLYSOMNOGRAPHY and Other Sleep Studies L36861
Effective Date: December 1, 2019 |
POLYSOMNOGRAPHY and Other Sleep Studies A57697
Effective Date: December 1, 2019 |
Noridian Healthcare Solutions, LLC
Jurisdiction F |
POLYSOMNOGRAPHY and Other Sleep Studies L34040
Effective Date: December 1, 2019 |
POLYSOMNOGRAPHY and Other Sleep Studies A57698
Effective Date: December 1, 2019 |
Palmetto GBA, LLC
Jurisdiction J, M |
POLYSOMNOGRAPHY L36593
Effective Date: October 14, 2021 |
POLYSOMNOGRAPHY A56995
Effective Date: September 9, 2021 |
First Coast Service Options, Inc.
Jurisdiction N |
POLYSOMNOGRAPHY and Sleep Testing L33405
Effective Date: July 1, 2020 |
POLYSOMNOGRAPHY and Sleep Testing A57496
Effective Date: July 7, 2021 |
Novitas Solutions, Inc.
Jurisdictions H, L |
Outpatient Sleep Studies L35050
Effective Date: January 1, 2021 |
Outpatient Sleep Studies A56923
Effective Date: September 12, 2019 |
National Government Services, Inc.
Jurisdictions 6, K |
N/A | Polysomnography and Sleep Studies A53019
Effective Date: October 31, 2019 |
Hypoglossal Nerve Stimulation for the Treatment of OSA
DME Medicare Administrative Contractors
DME MAC Jurisdiction | States in which Part A & Part B Claims are Processed | MAC |
---|---|---|
DME A | Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont | Noridian Healthcare Solutions, LLC |
DME B | Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin | CGS Administrators, LLC |
DME C | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico, U.S. Virgin Islands | CGS Administrators, LLC |
DME D | Alaska, Arizona, California, Hawaii, Idaho, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands | Noridian Healthcare Solutions, LLC |
DME – Local Coverage Determinations
The following chart lists all of the LCDs and Local Coverage Articles for Positive Airway Pressure (PAP) devices and Oral Appliances for the treatment of OSA.
DME MAC | LCD | Local Coverage Article |
---|---|---|
CGS Administrators, LLC
Jurisdictions B, C Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718)
Effective Date: January 1, 2020 |
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – Policy Article (A52467)
Effective Date: August 8, 2021 |
Oral Appliances for Obstructive Sleep Apnea (L33611)
Effective Date: January 1, 2020 Respiratory Assist Devices (L33800) Effective Date: August 8, 2021 |
Oral Appliances for Obstructive Sleep Apnea – Policy Article (A52512)
Effective Date: August 8, 2021 Respiratory Assist Device – Policy Article (A52517) Effective Date: August 8, 2021 |
DME MAC– Dear Physician Letters
DME MACs have developed Dear Physician Letters, to highlight requirements for sleep study scoring. Adhering to the information provided in the letters allows providers to ensure that information documented and shared with suppliers will lead to the provision of the best care for patients by helping them obtain and keep the needed equipment in accordance with DME MAC requirements.
DME MAC | Dear Physician Letter |
---|---|
Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Positive Airway Pressure (PAP) Devices: Initial Qualification Revised: August 2021 |
Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Positive Airway Pressure (PAP) Devices: Replacement Revised: April 2021 |
CGS Administrators, LLC Jurisdictions B, C |
Sleep Test Scoring and Medicare Revised: March 2021 |
Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Sleep Test Scoring and Medicare Revised: March 2021 |
Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Respiratory Assist Devices (RAD) for Central Sleep Apnea or Complex Sleep Apnea Revised: August 2021 |
Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Positive Airway Pressure (PAP) Devices: Clinician Frequently Asked Questions Shared: December 2008 |
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.