You can’t get CPAP covered, or prescribed responsibly, without a sleep test. The choice is a home sleep apnea test (HSAT) or an attended polysomnogram (PSG) in a sleep lab. Here’s what the American Academy of Sleep Medicine (AASM) and Medicare say.
The AASM 2017 diagnostic guideline
| # | Recommendation | Strength |
|---|---|---|
| 1 | Don’t use questionnaires, clinical tools or prediction algorithms to diagnose OSA without PSG or HSAT | Strong |
| 2 | Use PSG, or HSAT with a technically adequate device, for uncomplicated adults with signs and symptoms of increased risk of moderate to severe OSA | Strong |
| 3 | If a single HSAT is negative, inconclusive or technically inadequate, do PSG | Strong |
| 4 | Use PSG rather than HSAT with significant cardiorespiratory disease, potential respiratory muscle weakness from neuromuscular conditions, awake hypoventilation or suspected sleep-related hypoventilation, chronic opioid use, history of stroke, or severe insomnia | Strong |
| 5 | If clinically appropriate, a split-night PSG (diagnosis and CPAP titration in one night) rather than full-night diagnostic PSG | Weak |
| 6 | If the first PSG is negative and suspicion remains, consider a second PSG | Weak |
Source: Kapur et al., AASM clinical practice guideline, 2017.
Home vs lab at a glance
| Home sleep apnea test | In-lab polysomnography | |
|---|---|---|
| Where | Your own bed | Sleep lab, attended by a technologist |
| Best for | Uncomplicated adults with likely moderate to severe OSA (AASM) | Complex cases (list above), negative/inconclusive HSAT, other suspected sleep disorders |
| Can titrate CPAP the same night | No | Yes, with a split-night protocol |
| Detects non-respiratory sleep disorders | No | Yes |
| Accepted by Medicare for CPAP | Yes: Type II, III or IV with at least 3 channels | Yes (Type I) |
Medicare details from NCD 240.4 and the PAP LCD L33718.
What Medicare requires around the test
Under the DME MAC PAP policy (L33718):
| Requirement | Detail |
|---|---|
| Before the test | An in-person clinical evaluation by your treating practitioner to assess for OSA |
| Test | A Medicare-valid sleep test (Type I, II, III, IV or Other), FDA-approved as a diagnostic device |
| Qualifying result | AHI or RDI of 15 or more per hour (minimum 30 events), or 5–14 per hour (minimum 10 events) with documented sleepiness, impaired cognition, mood disorders or insomnia, or hypertension, ischemic heart disease or history of stroke |
| After starting CPAP | 12-week trial: use at least 4 hours a night on 70% of nights in a consecutive 30-day period during the first 3 months, plus a re-evaluation showing benefit |
| If you fail the trial | In-person re-evaluation and a repeat sleep test in a facility (Type I) to requalify |
More in Medicare CPAP coverage and the 90-day rule.
Which should you ask for?
- Healthy apart from snoring, sleepiness and witnessed apneas? A home test is reasonable under AASM guidance and usually more convenient.
- Heart failure, COPD, neuromuscular disease, opioids, stroke or severe insomnia? Ask for an in-lab study (AASM recommendation 4). Central apnea and hypoventilation can need different treatment; see APAP vs CPAP vs BiPAP and ASV coverage.
- Home test negative but still symptomatic? Ask for PSG (recommendation 3).
Verdict
A home sleep test is a valid first test for most uncomplicated adults, and Medicare accepts it for CPAP. In-lab PSG is the right call for complex medical histories and whenever a home test comes back negative or inconclusive. Either way, see your practitioner in person first if you’re on Medicare, and don’t rely on a questionnaire alone.
Related: getting a CPAP prescription online, sleep apnea treatment alternatives to CPAP, CPAP buyer’s guide.