Medicare coverage for repeat sleep study

[Bright Choice]

My doc wants me to have a third sleep study. I had one done 5/10 and a second 10/10. The first was a straight sleep study (a whopping 2 hours and 16 minutes of sleep), the other a titration. Neither study provided sufficient data for Medicare approval of cpap.

Since 12/29/10 I've been using an S9 Autoset with great results.

Neither the doc nor the sleep study lab have been able to get an answer about how often Medicare will cover sleep studies. Do any of you know whether it goes by the calendar year or by a 12 month interval or exactly what the coverage is? Any suggestions or comments would be appreciated. Thanks.

[Crayongrl]

Repeat testing is covered by Medicare and there are no "utilization* barriers.

However, your Zone or Region may have an internal utilization limit that ends up kicking a claim out for review. As long as your physician and Sleep Lab have the required documentation, there shouldn't be a problem.

Here's an excerpt from the Polysomnography and Sleep Studies local coverage determination policy:

Initial polysomnography and MSLT occasionally fail to identify narcolepsy.

Repeat polysomnography may be indicated:

• if the first study is technically inadequate due to equipment failure;
• if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis;
• if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed; or
• if the results were inconclusive or ambiguous.


AND

Follow-up polysomnography or cardiorespiratory sleep studies are not routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP treatment.

Follow-uppolysomnography or cardiorespiratory sleep studies may be indicated, however, for the following conditions:
• After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related
breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure;
• After substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed; or
• When clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP.


Here is a copy of the policy http://www.medicarenhic.com/pa/policies ... 26428).pdf

[Slinky]

Have you asked WHY your doctor wants another in-lab sleep study if you are doing so well on the S9 AutoSet??? I would have to have an answer to that that made sense to me before I would give any more consideration to this matter.