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

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 27, 2023

POLYSOMNOGRAPHY and Other Sleep Studies A56903

Effective Date: July 27, 2023

Wisconsin Physicians Service Insurance Corporation

Jurisdiction 5, 8

Surgical Treatment of Obstructive Sleep Apnea (OSA) L34526

Effective Date: July 27, 2023

Surgical Treatment of Obstructive Sleep Apnea (OSA) A56905

Effective Date: July 27, 2023

CGS Administrators, LLC

Jurisdiction 15

POLYSOMNOGRAPHY and Other Sleep Studies L36902

Effective Date: January 26, 2023

POLYSOMNOGRAPHY and Other Sleep Studies A57049

Effective Date: January 26, 2023

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: March 16, 2023

POLYSOMNOGRAPHY A56995

Effective Date: March 16, 2023

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: January 1, 2023

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

MAC LCD Local Coverage Article
Novitas Solutions, Inc.

Jurisdictions H, L

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38385

Effective Date: March 15, 2020

Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea A56938

Effective Date: January 1, 2022

First Coast Service Options, Inc.

Jurisdiction N

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38398

Effective Date: March 15, 2020

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea A56953

Effective Date: January 1, 2022

Noridian Healthcare Solutions, LLC

Jurisdiction E

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38310

Effective Date: March 15, 2020

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea A57948

Effective Date: March 15, 2020

Noridian Healthcare Solutions, LLC

Jurisdiction F

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38312

Effective Date: March 15, 2020

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea A57949

Effective Date: March 15, 2020

National Government Services

Jurisdictions 6, K

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38387

Effective Date: April 1, 2020

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea A57092

Effective Date: January 1, 2022

CGS Administrators

Jurisdiction 15

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38307

Effective Date: March 2, 2023

Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea A57149

Effective Date: March 2, 2023

Wisconsin Physician Service Insurance Corporation

Jurisdictions 5, 8

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38528

Effective Date: June 14, 2020

Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea A57944

Effective Date: June 14, 2020

Palmetto GBA

Jurisdictions J, M

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38276

Effective Date: April 13, 2023

Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea A58075

Effective Date: January 1, 2022

 

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 devices, oral appliances, and respiratory assist devices.

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: September 27, 2021

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

Oral Appliances for Obstructive Sleep Apnea – Policy Article (A52512)

Effective Date: August 8, 2021

Respiratory Assist Devices (L33800)

Effective Date: August 8, 2021

Respiratory Assist Device – Policy Article (A52517)

Effective Date: August 8, 2021

 

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.

DME MAC Resources
Noridian Healthcare Solutions, LLC
Jurisdictions A, D
Dear Clinician Letter: Positive Airway Pressure (PAP) Devices: Initial Qualification
Revised: August 2021
Dear Clinician Letter: Positive Airway Pressure (PAP) Devices: Replacement
Revised: April 2021
Dear Clinician Letter: Documentation of Continued Medical Necessity
Revised: July 2021
Dear Clinician Letter: An Easy Option for Documenting Continued Use
Revised: July 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
Clinician Checklist Positive Airway Pressure (PAP)
Revised: December 2021
Noridian Healthcare Solutions, LLC
Jurisdictions A, D
PAP Devices Documentation Checklist
Revised: November 2021
Noridian Healthcare Solutions, LLC
Jurisdictions A, DCGS Administrators, LLC
Jurisdictions B, C
Standard Documentation Requirements for All Claims Submitted to DME MACs
Revised: April 2022

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.