[Chuck]

Does anyone have a clear answer on how long Medicare considers a Sleep Study to be valid for?

I called Medicare (NHIC) they told me “we can use any sleep study available just need an updated detailed order and proof of a current Face to Face visit”. Resmed said “unwritten fact that its good for life” someone else said you need a new sleep study for a CPAP when a patient goes from a commercial insurance onto Medicare. We often run into situations where a patient had a sleep study several years ago, never received a cpap and now has a new Rx for a cpap. I can’t find anything in writing on this. Thanks

[Sleeping410]

A diagnostic study (as far as Medicare billing is concerned) is good for a lifetime. If the patient was not Medicare when the study was recorded, they must have a face to face with their treating physician when they become Medicare FFS in order to get a replacement PAP or supplies.

From the Medicare LCD

BENEFICIARIES ENTERING MEDICARE:

For beneficiaries who received a PAP device prior to enrollment in fee for service (FFS) Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the following coverage requirements must be met:

1. Sleep test – There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and,
2. Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating physician who documents in the beneficiary’s medical record that:
   1. The beneficiary has a diagnosis of obstructive sleep apnea; and,
   2. The beneficiary continues to use the PAP device.
   If either criteria 1 or 2 above are not met, the claim will be denied as not reasonable and necessary.
   
   In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.