Does Medicare Cover Sleep Studies?
Medicare covers sleep studies when the test is ordered by your doctor to diagnose certain conditions, including sleep apnea, narcolepsy and parasomnia. Sleep studies can take place at a sleep clinic or in your home. Medicare Part B covers 80 percent of the cost for sleep studies.
Medicare Sleep Study Guidelines
Medicare covers sleep tests and studies when they are ordered by your doctor.
Sleep studies are considered diagnostic services covered by Medicare only if you have symptoms of certain conditions.
- Sleep apnea
- Parasomnia, including sleepwalking, night terrors and rapid eye movement (REM) sleep behavior disorders
Your sleep study can take place at a sleep disorder clinic or a clinic affiliated with a hospital or overseen by a physician.
Polysomnography is the medical term for a sleep study. Polysomnography records your brain waves, heart rate and breathing, as well as the oxygen level in your blood and eye and leg movements during sleep.
Medicare does not cover sleep studies used to diagnose patients with chronic insomnia.
Sleep Studies for Diagnosing Obstructive Sleep Apnea (OSA)
Sleep studies are often required to formally diagnose patients with sleep apnea.
You must undergo a face-to-face evaluation with your doctor prior to your sleep study. Your obstructive sleep apnea symptoms must be documented in your medical record before your doctor writes an order or referral for a sleep study.
- Type I
- This type of attended sleep study is covered by Medicare when it is performed at a facility with the oversight of a sleep technologist to aid the diagnosis of obstructive sleep apnea. Type I, which is typically performed in a facility, is considered the reference standard for diagnosing obstructive sleep apnea.
- Type II
- Type II is a home sleep test performed using a portable monitor with a minimum of seven channels. Medicare covers Type II testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
- Type III
- Type III is a home sleep test performed using a portable monitor with a minimum of four channels. Medicare covers Type III testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
- Type IV
- Type IV uses at-home sleep study devices that measure, at a minimum, three channels: airflow, heart rate and oxygen saturation. Medicare covers Type IV testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
Your Cost for a Sleep Study Under Medicare
Sleep studies are considered a diagnostic test and must be ordered by your doctor to qualify for Medicare coverage.
Sleep studies are covered by Medicare Part B. You will owe 20 percent of the Medicare-approved cost of the study, and the Part B deductible applies.
You may owe less if you have supplement insurance, such as Medicaid or a Medigap policy.
If you’re enrolled in a Medicare Advantage plan, you may be restricted to sleep centers and clinics within your plan’s provider network.
Medicare Coverage for Treating Sleep Apnea
Medicare covers the diagnosis and treatment of obstructive sleep apnea when certain criteria are met.
Sleep apnea is a serious medical condition in which a patient stops breathing during sleep. It is often underdiagnosed.
The prevalence of sleep apnea increases with age. Up to 10 percent of people aged 65 and older have the condition.
- Excessive daytime sleepiness
- Concentration difficulty
- Coronary artery disease
A continuous positive airway pressure, or CPAP, machine, is the treatment of choice for obstructive sleep apnea.
Medicare Part B partially covers the cost of a CPAP machine as durable medical equipment.
In order to receive a CPAP machine through Medicare, you must first undergo a sleep study.
After the sleep study, your primary care doctor will review the results with you during a follow-up appointment.
Your doctor will use the data gathered to determine a formal diagnosis and discuss any treatment or further evaluations you may need.
- The CPAP must be ordered by your doctor.
- Your doctor must teach you or your caregiver how to use the machine before you receive it.
- Your obstructive sleep apnea diagnosis must include a clinical evaluation of a sleep study performed in a sleep laboratory or an unattended home sleep test with a Type II, Type III or Type IV home sleep monitoring device.
Medicare initially limits coverage of a CPAP machine to a 12-week rental period during which your doctor assesses any improvement in your conditions as a result of using the machine.
Surgery is another treatment option for sleep apnea. Your doctor may recommend surgery if using a CPAP machine proves ineffective in treating your condition.
When you meet specific criteria, Medicare Part A should cover the surgery.
- Mandibular maxillary osteotomy advancement
- Genioglossus advancement with or without hyoid suspension
If your sleep apnea is caused by abnormalities in your upper airway — such as enlarged tonsils or an enlarged tongue — Medicare will cover surgery to fix these abnormalities. The surgery must be deemed medically necessary and supported by documentation in your medical record for you to qualify for coverage.
Medicare does not cover laser-assisted uvuloplatoplasty surgery.
8 Cited Research Articles
- United Healthcare. (2021, February 8). Sleep Apnea: Diagnosis and Treatment. Retrieved from https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/sleep-apnea-diagnosis-treatment.pdf
- Mayo Clinic. (2020, December 1). Polysomnography (sleep study). Retrieved from https://www.mayoclinic.org/tests-procedures/polysomnography/about/pac-20394877
- Florida Dental Sleep Disorders. (2019, October 16). Do I Need a Doctor’s Referral to Undergo a Sleep Test? Retrieved from https://bocaratondentalsleepmedicine.com/blog/2019/10/do-i-need-referral-sleep-testing-vero-beach/
- Centers for Medicare & Medicaid Services. (2019). Provider Compliance Tips for Polysomnography (Sleep Studies). Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceTipsforPolysomnography-MLN4013531Print-Friendly.pdf
- Centers for Medicare & Medicaid Services. (n.d). Decision Memo for SLEEP TESTING for Obstructive SLEEP Apnea (OSA) (CAG-00405N). Retrieved from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=227&ver
- Cleveland Medical Devices. (n.d.). Type I, Type II, Type III Sleep Monitors, CMS AASM Guidelines. Retrieved from https://clevemed.com/cms-aasm-guidelines-for-sleep-monitors-type-i-type-ii-type-iii/
- Medicare.gov. (n.d.). Sleep studies. Retrieved from https://www.medicare.gov/coverage/sleep-studies
- National Government Services, Inc. (n.d.). LCD for Polysomnography and Sleep Studies (L26428). Retrieved from https://aasm.org/resources/pdf/ngspoly.pdf