Impotence - Diagnostic nocturnal penile tumescence testing may be covered, under limited circumstances, to determine whether erectile impotence in men is organic or psychogenic. Although impotence is not a sleep disorder, the nature of the testing requires that it be performed during sleep. The tests ordinarily are covered only where necessary to confirm the treatment to be given (surgical, medical, or psychotherapeutic). Ordinarily, a diagnosis may be determined by two nights of diagnostic testing. If more than two nights of testing are claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional tests. It will have its medical staff review questionable cases to ensure that the tests are reasonable and necessary for the individual. It will use HCPCS procedure code 54250. (See the Medicare National Coverage Determinations Manual, Chapter 1, for policy on coverage of diagnosis and treatment of impotence.)
. Parasomnia - Parasomnias are a group of conditions that represent undesirable or unpleasant occurrences during sleep. Behavior during these times can often lead to damage to the surroundings and injury to the patient or to others. Parasomnia may include conditions such as sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorders. In many of these cases, the nature of these conditions may be established by careful clinical evaluation. Suspected seizure disorders as possible cause of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis. The carrier must use HCPCS procedure codes 95807, 95810, and/or 95822.
Coverage of Therapeutic Services.
Sleep disorder clinics may at times render therapeutic as well as diagnostic services. Therapeutic services may be covered in a hospital outpatient setting or in a freestanding facility provided they meet the pertinent requirements for the particular type of services and are reasonable and necessary for the patient, and are performed under the direct supervision of a physician.