Does Medicaid Cover Sleep Studies?

In this article...
  • If you might have a sleep disorder, your doctor could order a clinical sleep study to learn more. Find out whether Medicaid will cover any costs for a sleep study.

If your doctor believes you're exhibiting signs of sleep disorders, he may refer you to a polysomnography — more widely known as a clinical sleep study. These studies require overnight evaluation to diagnose the severity of your symptoms and how they're affecting your sleep continuity, cardiac functions and other factors. This may be in the form of a sleep lab study or a home test. Find out more about whether Medicaid covers sleep studies below.

Does Medicaid Cover Sleep Studies?

Some state Medicaid programs do cover clinical sleep studies, including home tests. However, sleep studies conducted in the home of an enrollee are typically only covered under certain circumstances. For a test to be covered, it may need to be performed under the direct supervision of one of the following:

  • A hospital-based sleep lab.
  • A sleep clinic that is a direct extension of a physician’s office.
  • An IDTF (independent diagnostic testing facility).
  • An entity accredited by the American Academy of Sleep Medicine (AASM) as an Out of Center Sleep Testing entity.

What Is Out of Center Sleep Testing?

Out of Center Sleep Testing (OCST) refers to options including Home Sleep Tests (HST), Portable Monitoring (PM), and Out Of the Facility (OOF) testing.

For a provider to be accredited as a legitimate OCST entity by the AASM, and subsequently potentially covered by Medicaid, the provider must be able to verify the attendant physician’s training, knowledge, and experience. As sleep study enrollees must undergo very thorough examinations, the AASM considers the skill and accuracy of the physician’s diagnostic capabilities absolutely vital. Any physician issuing medical direction during these studies must possess a valid practitioner’s license in the corresponding state. It's also expected that the physician routinely updates and educates the sleep study participant after evaluation, diagnosis and development of a proper treatment plan.

In addition, at least one properly educated and experienced technician must also be present throughout the duration of the study, and the space and equipment used must be in accordance with the AASM’s documentation requirements. 

Any facility-based or OCST sleep study not affiliated with a hospital in which the beneficiary’s personal health is compromised by virtue of immobility, safety or severe illness will not likely be covered by Medicaid. Coverage may also be denied in the case of a beneficiary with comorbid conditions or symptoms that may directly affect the accuracy of a diagnosis or when treatment is considered too urgent for a standard sleep study to be safely performed.

How Can Sleep Apnea Be Treated?

There are many ways sleep apnea can be treated. The most common and widely used treatment for moderate to severe sleep apnea is the use of positive airway pressure machines with breathing masks. The mask is worn over the beneficiary’s nose during sleep (or sometimes both nose and mouth) while the machine pumps pressurized air into their airways. This form of therapy is often referred to as continuous positive airway pressure (CPAP). Alternative forms of treatment for sleep apnea include:

  • Wearing an oral/dental appliance 
  • Palate surgical procedures such as uvulopalatopharyngoplasty (UPPP), expansion sphincter pharyngoplasty or lateral pharyngoplasty
  • Undergoing a weight management program
  • Positional therapy

Does Medicaid Cover CPAP?

Many sleep study diagnoses are treated using therapies such as CPAP, particularly for beneficiaries experiencing severe and unambiguous obstructive sleep apnea. The use of CPAP is covered under Medicaid when prescribed by the attending licensed technician.

However, if the beneficiary has been utilizing CPAP therapy under a different insurance plan and is looking to switch to Medicaid, the issue requiring CPAP may be considered a preexisting condition. In this case, the beneficiary must first be found in accordance with all applicable policy guidelines. This typically includes an initial doctor’s visit, even in the event that you are currently using CPAP therapy or have in the past. 

To find out more about how much your sleep study may cost you, talk to your doctor or health care provider.

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