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

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

The following chart lists all sleep policy LCDs organized by MAC.

DME Medicare Administrative Contractors

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– 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.

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.