Noridian Healthcare Solutions, the Medicare Administrative Contractor (MAC) for Jurisdiction J-F, recently adopted utilization guidelines for its local coverage determination policy (LCD), Polysomnography and Other Sleep Studies (L34040). Updated in June 2017, the LCD policy affects Part A and B providers in several states, including Arizona and Washington.
The utilization guidelines state:
“More than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.”
Wisconsin Physician Services Insurance Corporation (WPS); CGS Administrators, LLC; and Noridian Healthcare Solutions, LLC, also have included these utilization guidelines in their LCDs for polysomnography and other sleep studies.