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TrailBlazer Issues New LCD Policy

On July 25, TrailBlazer Health Enterprises released its new Local Coverage Determination (LCD) policy titled "Polysomnography and Sleep Studies." The policy went into effect on July 28, 2008.

TrailBlazer covers primary geographic jurisdiction in Colorado, New Mexico, Oklahoma, and Texas. See the policy for specific region definitions.

Home sleep testing services (G0398, G0399, G0400) for the purpose of diagnosing obstructive sleep apnea are covered by the TrailBlazer policy “if the home sleep test is reasonable and necessary for the diagnosis of the patient’s condition, meets all other Medicare requirements, and the physician who performs the service has sufficient training and experience to reliably perform the service,” the LCD states.

The policy also states, “Medicare considers it unlikely that it will be reasonable and necessary for a patient to have more than one home sleep test in a year.” Lacking from the policy is CPT code 95806, which has been removed from the coding list.

According to the policy, the physician performing the service must meet one of the following:
• The physician is a diplomate of the American Board of Sleep Medicine (ABSM).
• The physician is a diplomate in sleep medicine by a member board of the American Board of Medical Specialties (ABMS).
• The physician is an active staff member of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM) or The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)).

All of the following requirements must be met when performing a diagnostic test in order to be covered by the new TrailBlazer policy:

• The clinic either is affiliated with a hospital or is under the direction and control of physicians. (Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician.)
• Patients are referred to the sleep disorder clinic by their attending physicians and the clinic maintains a record of the attending physician’s orders.
• The need for diagnostic testing is confirmed by medical evidence (eg, physician examinations and laboratory tests).
The results of standard polysomnograms must be interpreted by either a physician or doctoral level professional with satisfactory training in sleep medicine.

The TrailBlazer policy also states, “A home sleep test is covered only when it is performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.”

TrailBlazer will not cover home sleep testing for persons with comorbidities or other sleep disorders, or for screening asymptomatic persons. See the policy for specific clarification.

The policy is available here.