Medical Review Frequently Asked Questions (FAQs)

Q1. Is Targeted Probe and Educate (TPE) going to restart for Part B?
A1. Yes. Notification letters are being sent out as of September 1, 2021. Please see more information on the Noridian Targeted Probe and Educate (TPE) webpage, as well as in the Latest Update article titled: Targeted Probe and Educate (TPE) Resumption. Note: Provider Outreach and Education is holding several webinars on the topic of TPE. Visit the Schedule of Events to register for one of these events.

Q2. If the Positive Airway Pressure (PAP) supplier is requiring a repeat polysomnography (PSG) due to non-compliance would it be medically necessary to perform a repeat polysomnography?
A2. According to the Local Coverage Determination, "Polysomnography and Other Sleep Studies," repeat polysomnography's are covered for the following follow-up indications:

  • "To evaluate the response to treatment (CPAP, oral appliances or surgical intervention);
  • 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 symptomatic again despite 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."

Therefore, if the indications above are not met, then an Advance Beneficiary Notice (ABN) may be used. Medical necessity is met when the patient needs a PSG due to signs and symptoms of Obstructive Sleep Apnea (OSA), Parasomnias and Narcolepsy. This is generalized information; medical necessity is different in each individual case. Please refer to the LCD "Polysomnography and Other Sleep Studies," Polysomnography and Other Sleep Studies (L36861) LCD.

Q3. When should a beneficiary be tested for vitamin D levels?
A3. Once a beneficiary has been shown to be vitamin D deficient, further testing may be medically necessary only to ensure adequate replacement has been accomplished. If Vitamin D level is between 20 and 50 ng/dl and patient is clinically stable, repeat testing is often unnecessary; if performed, documentation most clearly indicate the necessity of the test. If level 60 ng/dl, a subsequent level(s) may be reimbursed until the level is within the normal range. Reference: Vitamin D Assay Testing (L36692) LCD.

Q4. How am I able to find the date of the beneficiaries last polysomnography?
A4. Unfortunately, providers are unable to access this information However a beneficiary can contact Medicare and have a representative look up this information. The phone number is: 800-Medicare.

The beneficiary can then inform the provider or the sleep center/lab.

 

Last Updated Thu, 30 Sep 2021 15:24:18 +0000