Medical Policy Bulletin

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Title:

Adult Sleep Disorder Testing

Policy #:

07.03.05i

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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the medical necessity criteria for adult sleep disorder testing.

For information on topics related to adult sleep disorder testing, such as the treatment of obstructive sleep apnea and noninvasive respiratory assist devices (eg, continuous positive airway pressure [CPAP]) and sleep studies related to nocturnal penile tumescence testing, refer to the Cross References section in this policy.

Description

Sleep studies refer to the continuous and simultaneous monitoring and recording of various physiologic and pathophysiologic parameters of sleep. The normal nocturnal sleep cycle in adults consists of two distinct states: rapid eye movement (REM), also called dream sleep, and nonrapid eye movement (NREM). Sleep tests are performed to diagnose sleep disorders (eg, narcolepsy, sleep apnea, parasomnias) and/or evaluate an individual's response to therapies such as continuous positive airway pressure (CPAP).

Sleep disorder testing determines an individual's apnea-hypopnea index (AHI) and respiratory distress index (RDI). The AHI combines apneas and hypopneas and provides a measurement for the severity of sleep apnea. A hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30 percent reduction in airflow (as compared to baseline) and at least a 4 percent decrease in oxygen saturation. AHI is equal to the average number of episodes of apnea and hypopnea per hour of sleep. The respiratory disturbance index (RDI) is equal to the average number of respiratory disturbances per hour of sleep. Sleep tests are scored according to the number of apneic episodes or respiratory disturbances the individual experiences per hour of sleep.

AHI and RDI are calculated without the use of a positive airway pressure device. If the AHI or RDI is based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a 2-hour period.

Polysomnography (PSG), also known as Level/Type I sleep testing, is an attended sleep study that involves sleep staging. The study includes the following: a 1-to-4 lead electroencephalogram (EEG), electro-oculogram (EOG), submental electromyogram (EMG), and electrocardiogram (ECG). The timing and length of PSG testing should mirror that of the individual's usual sleep pattern. PSG testing involves the observation of nasal and/or oral airflow, ventilation, and respiratory effort. Other tests and observations that may pertain to PSG include:

• Monitoring of oxygen saturation through oximetry
• Transcutaneous monitoring or end-tidal gas analysis
• Extremity muscle activity
• Motor activity movement
• Monitoring of extended EEG
• Monitoring of gastroesophageal reflux
• Monitoring of blood pressure
• Monitoring of snoring
• Monitoring of body positions

SLEEP APNEAS

Sleep apnea is a respiratory dysfunction resulting in the cessation, or near cessation, of respiration for a minimum of 10 seconds. These cessations of breathing may be due to either absence of respiratory effort (central sleep apnea [CSA]—relatively rare), an occlusion of the airway (obstructive sleep apnea [OSA]—most common), or a combination of these factors (mixed sleep apnea).

The most common nighttime symptoms of sleep apnea are severe snoring and abnormal motor activity (eg, flailing of the extremities). The most common daytime symptoms are excessive sleepiness due to sleep disruption, and cognitive impairment, including poor memory and personality changes.

CSA is defined by the following:

• An AHI greater than 5
• Central apneas/hypopneas greater than 50 percent of the total apneas/hypopneas
• Central apneas or hypopneas greater than or equal to 5 times per hour
• Symptoms of either excessive sleepiness or disrupted sleep
  

Complex sleep apnea is a form of CSA specifically identified by the persistence or emergence of central apneas or hypopneas upon exposure to CPAP device when obstructive events have disappeared. These individuals have predominantly obstructive or mixed apneas during a diagnostic sleep study occurring at greater than or equal to 5 times per hour. With the use of a CPAP and/or bi-level device, they show a pattern of apneas and hypopneas that meets the definition of CSA described above.

OSA is usually caused by one of the following:

• Reduced upper airway capacity due to obesity
• Adenotonsillar hypertrophy
• Mandibular deficiency
• Macroglossia or upper airway tumor
• Excessive pressure across the collapsible segment of the upper airway
• Insufficient activity of the muscles of the upper airway to maintain patency

OSA is diagnosed by a combination of symptoms and laboratory findings. Overnight PSG is the optimal diagnostic test for sleep apnea. In certain circumstances, unattended sleep studies in an individual's home using portable devices have been accepted as an alternative to PSG for the diagnosis of OSA.

These portable devices are graded according to their level of data-gathering sophistication, into Levels/Types II, III and IV:

• Type II devices monitor and record a minimum of seven channels: EEG, EOG, EMG, ECG, airflow, respiratory effort, and oxygen saturation.
• Type III devices monitor and record a minimum of four channels: respiratory effort, airflow, ECG, and oxygen saturation.
• Type IV devices monitor and record a minimum of three channels, one of which must be airflow, that allow direct calculation of an AHI or RDI, as previously defined.

OSA is diagnosed by either of the following:

• AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documentation of one or more, of the following symptoms:
  • Excessive daytime sleepiness
  • Impaired cognition
  • Mood disorders
  • Insomnia
  • Hypertension
  • Ischemic heart disease
  • History of stroke
• AHI or RDI is greater than or equal to 15 events per hour, with a minimum of 30 events

Without evidence of OSA, a supervised sleep study is not indicated for evaluation of individuals undergoing laser-assisted uvulopalatopharyngoplasty (LAUP) or who have chronic lung disease.

MULTIPLE SLEEP LATENCY TEST

The multiple sleep latency test (MSLT) is a standardized and well-validated measure of pathophysiologic sleepiness. The same parameters as the basic PSG are monitored (ie, eye movements, EEG [central and occipital] channels, EKG, airflow, and EMG). The MSLT consists of four to five 20-minute nap opportunities offered at 2-hour intervals. The MSLT is designed to quantify sleepiness to assess the need for treatment and to determine the premature occurrence of REM sleep. Studies in normal individuals have demonstrated that the latency period (time to sleep onset) during these naps is correlated with the individual's age, continuity of sleep, time of day, ingestion of drugs, and duration of sleep on one or several nights preceding the study. Pathologic ranges of sleep latency have been carefully defined. Interpretation of the MSLT should be made following a PSG performed on the preceding night. For each nap, the latency period between lights out and sleep onset is determined. A mean latency period of 8 minutes or less indicates excessive sleepiness. The number of naps during which REM sleep appears also is noted.

NARCOLEPSY

Narcolepsy is a neurologic disorder of unknown etiology characterized predominantly by abnormalities of REM sleep, some abnormalities of NREM sleep, and the presence of excessive daytime sleepiness, often with involuntary daytime sleep episodes. Other symptoms of narcolepsy include cataplexy (an abrupt attack of muscular weakness and hypotonia triggered by an emotional stimulus such as anger, fear, or surprise) and other REM sleep phenomena, such as sleep paralysis and hypnagogic hallucinations (vivid dream-like experiences that the individual cannot distinguish from reality). The diagnosis of narcolepsy is usually confirmed by an overnight PSG, followed by an MSLT the next day. The following measurements are usually indicative of narcolepsy:

• PSG assessment of the quality and quantity of night-time sleep
• Mean sleep latency of 8 minutes or less for several naps in the MSLT
• The presence of two or more sleep-onset REM periods during the MSLT

PARASOMNIAS

Parasomnias are a group of sleep disorders associated with brief or partial arousals but not with marked sleep disruption or excessive daytime sleepiness. The presenting complaint is usually related to the behavior itself. Most parasomnias are more common in children but may persist into adulthood when their occurrence has more pathologic significance. Behavior during these times can often lead to damage to the individual's surroundings and injury to the individual or to others. Parasomnias include the following conditions:

• Confusion arousals
• Somnambulism (sleepwalking)
• Sleep terrors
• REM sleep behavior disorder (a rare parasomnia affecting mostly middle-aged and older men with a history of neurological disease, characterized by violent behavior during sleep)
• Sleep-related epilepsy
• Sleep bruxism (an involuntary, forceful grinding of the teeth during sleep that affects 10 percent to 20 percent of the population)
• Sleep enuresis (bed wetting)
• Miscellaneous conditions (nocturnal head banging, sleep talking, restless leg syndrome, periodic limb movement disorder, and nocturnal leg cramps)

PSG testing with additional EEG channels is usually used to assist with the diagnosis of suspected paroxysmal arousals for other sleep disruptions that are thought to be seizure-related when initial clinical evaluation and results of a standard EEG are inconclusive. PSG testing is not routinely used for individuals with epilepsy who have no specific symptoms consistent with a sleep disorder.

PSG FOR CHRONIC INSOMNIA

Presently, there is no supporting evidence that PSG testing for individuals with chronic insomnia provides definitive diagnostic data or that such information is associated with improved clinical outcomes.

Policy

MEDICALLY NECESSARY

SLEEP DISORDER TESTING
Sleep disorder testing with physician review, interpretation, and report, is considered medically necessary and, therefore, covered for the initial diagnosis or follow-up evaluation for individuals who have symptoms or complaints of any of the following conditions/therapies:

• Narcolepsy
• Sleep apnea
• Parasomnias
• Impotence
• Neuromuscular disorders, such as myotonic dystrophy and sleep-related symptoms
• Severe snoring, when other evidence of sleep-disordered breathing is present (eg, rapid, shallow breathing)
• Continuous positive airway pressure (CPAP) requiring titration
• Paroxysmal arousals for other sleep disruptions that are seizure-related with both inconclusive EEG results and a documented history of repeated violent or injurious episodes during sleep
• Polysomnography (PSG) in an accredited site-of-service for Level I testing is indicated for any of the following:
  • To evaluate the response to initial PSG treatment (eg, CPAP, oral appliances, surgical intervention) or when symptoms return despite good initial response to treatment with CPAP
  • After substantial weight loss for individuals treated with CPAP for sleep-related breathing disorders
  • After substantial weight gain for individuals who were previously treated successfully with CPAP and are currently symptomatic despite the continued use of CPAP
  • When there has been a significant change in the individual's cardiorespiratory status, such as the development or worsening of congestive heart failure (CHF) or left ventricular dysfunction
  • For individuals who have negative test results from Level III UHSS
  • Split-night sleep study Nocturnal Polysomnography (NPSG), when the final portion of the NPSG is used to titrate CPAP

ATTENDED SLEEP TESTING
Attended sleep testing conducted in an accredited site-of-service is considered medically necessary and, therefore, covered when all of the following criteria are met:

• The accredited site-of-service is under the direction and control of a physician/Medical Director. The testing is covered in the absence of direct supervision of a physician when the data is interpreted by a physician.
• The individual is physician-referred to the provider-based sleep setting, and the provider maintains a record of the physician's orders and referral.
• The sleep test is ordered by the individual's treating physician.
• The need for the diagnostic sleep test is substantiated by medical evidence (eg, physician histories, examinations, test results) documented in the individual's clinical record.

Follow-up PSG testing is not routinely indicated in individuals treated with CPAP whose symptoms continue to resolve. However, PSG with CPAP titration is appropriate for individuals with any of the following indications:

• An apnea index (AI) of at least 20 per hour or an apnea-hypopnea index (AHI) of at least 15 per hour, regardless of the individual's symptoms
• An AHI of at least 5 per hour in an individual with excessive daytime sleepiness
• A respiratory arousal index of at least 10 per hour in an individual with excessive daytime sleepiness
• A clinical change, such as a significant change in body weight or the development of CHF or left ventricular dysfunction, indicating that the CPAP dose may need to be changed

For CPAP titration, a split-night study (initial PSG followed by CPAP titration during PSG on the same night) is an alternative to one full night of PSG followed by a second night of titration if any of the following criteria are met:

• An AHI of at least 30 per hour, documented during a minimum of two hours of PSG
• An AHI of 5 to 15 per hour, documented in an individual with associated stroke, excessive daytime sleepiness, or ischemic heart disease
• CPAP titration carried out for more than 3 hours
• Evidence of obstructive sleep apnea (OSA) documented during a minimum of 2 hours of PSG

UNATTENDED SLEEP TESTING FOR OSA

COMMERCIAL PRODUCTS
For individuals enrolled in commercial products, unattended sleep testing for OSA is considered medically necessary and, therefore, covered using the following:

• Level/Type III device (G0399) unattended portable sleep monitoring for cases of suspected OSA when at least one of the following are met:
  • The individual's physical condition prevents attendance at an accredited site-of-service (eg, immobility).
  • The individual lives in a geographic area where PSG is not available.
  • The individual exhibits severe clinical symptoms that are indicative of a diagnosis of moderate to severe OSA, when initiation of treatment is urgent, and standard PSG testing is not readily available.

Unattended sleep testing using the following devices are considered not medically necessary and, therefore, not covered for individuals enrolled in commercial products:

• Level/Type II device
• Level/Type IV device, measuring three or more channels, one of which being airflow or thoracoabdominal movement
• Sleep testing devices that measure three or more channels, one of which being airflow or thoracoabdominal movement, and may include actigraphy (measurement of movement), oximetry (oxygen saturation), and peripheral arterial tone (pulsatile volume changes), when used to aid in the diagnosis of OSA

MEDICARE ADVANTAGE PRODUCTS
For individuals enrolled in Medicare Advantage products, unattended sleep testing for OSA is considered medically necessary and, therefore, covered using the following devices:

• Level/Type II device
• Level/Type III device
• Level/Type IV devices: A type IV device must measure at least three channels, one of which must be airflow
• Sleep testing devices that measure three or more channels, one of which being airflow or thoracoabdominal movement, and may include actigraphy (measurement of movement), oximetry (oxygen saturation), and peripheral arterial tone (pulsatile volume changes), when used to aid in the diagnosis of OSA.

For unattended, portable home sleep studies, an individual must undergo a face-to-face clinical evaluation by a treating physician prior to a sleep test for the assessment of OSA.

Performance of unattended home sleep testing is limited to US Food and Drug Administration (FDA)-approved devices furnished with adequate patient instruction and support to assure successful completion and reliable results. Provision of the device, instruction, and support can be provided by sleep centers, physicians, and diagnostic testing facilities who can demonstrate use of FDA-approved devices, inspection of the devices, and the necessary patient-education support.

NOT MEDICALLY NECESSARY

PSG testing, multiple sleep latency tests (MSLTs), and cardiorespiratory sleep studies are considered not medically necessary and, therefore, not covered for the following situations:

• For the diagnosis of individuals with chronic insomnia
  • Please Note: Sleep studies are not covered for chronic insomnia and should not be ordered unless evaluation and clinical judgement by the treating physician determines that an individual's symptoms and complaints are indications of a covered condition (eg, routine insomnia, idiopathic hypersomnia) and are appropriate and reasonable for a sleep study.
• For the preoperative evaluation of individuals undergoing a laser-assisted uvulopalatopharyngoplasty (LAUP) without clinical evidence that OSA is suspected
• For the diagnosis of chronic lung disease
  • Please note: Nocturnal hypoxemia in individuals with chronic, obstructive, restrictive, or reactive lung disease is usually adequately evaluated by oximetry. However, if the individual’s symptoms suggest a diagnosis of OSA, PSG is considered medically necessary and, therefore, covered.
• For individuals in whom seizure disorders are suspected
• For typical, uncomplicated, and non-injurious parasomnias when the diagnosis can be evaluated by clinical assessment alone and when a clinical history, neurological exam, and routine electroencephalogram (EEG) are sufficient to establish a diagnosis
• For individuals with epilepsy who have no specific complaints consistent with a sleep disorder
• For individuals with symptoms suggestive of periodic limb movement disorder (PLMD) or restless leg syndrome (RLS), unless symptoms are suspected to be related to a covered indication
• Unattended sleep testing for any condition other than OSA

NOT ELIGIBLE FOR REIMBURSEMENT

Actigraphy is not eligible for reimbursement when billed alone or separately (ie, in conjunction with a sleep study).

An EEG, when reported with a PSG, is not separately reimbursable because an EEG is a component of a PSG.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The individual's medical record must document signs and symptoms to support reasonable and necessary indications for performing a sleep disorder test, including, but not limited to the following:

• Daytime somnolence
• Witnessed apneic episodes
• Reports of sleeping/napping during the day
• Falling asleep at work or when driving
• Witnessed nocturnal motor activity (eg, flailing)
  

A detailed patient history of sleep disorder (as noted) as well as a detailed physical exam, including one or more of the following examinations:

• Nose, throat, pharynx examination
• Cardiovascular examination
• Neurological examination
• General examination, body habitus and weight, and vital signs

For PSG testing, sleep must be recorded and staged. Repeat PSG testing for the diagnosis of sleep apnea must be accompanied with documentation justifying the medical necessity for the repeat test.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Level/Type I, polysomnography (PSG), sleep studies are to be performed in an accredited site-of-service (sleep lab/center, free-standing, office-based, or hospital affiliated), which is accredited by either the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or American Academy of Sleep Medicine (AASM). Sleep disorder centers are facilities in which certain illnesses are diagnosed through the study of sleep. The centers are typically under the direction and control of qualified physicians who are experienced and highly skilled in sleep disorder testing.

Diagnostic testing routinely performed in sleep disorder centers may be covered when direct supervision is provided by a technologist, and the data is interpreted by a physician. Individuals should be referred to a sleep disorder center by a physician, and the center should maintain a record of the physician's orders.

A multiple sleep latency test (MSLT) is not routinely indicated for most individuals with sleep-related breathing disorders. A subjective assessment of excessive daytime sleepiness should be obtained. An MSLT may be indicated in individuals with excessive daytime sleepiness despite the cessation of apnea or a significant decrease in the apnea-hypopnea index (AHI).

Sleep studies generally require at least 6 hours of recording to determine a diagnosis. Occasionally, a definitive diagnosis can be made with less than 6 hours of recording. In these cases, medical record documentation should support claims and must be supplied to the Company upon request.

Sleep testing should not be performed during the acute phase of an illness or injury.

PERSONNEL QUALIFIED TO CONDUCT HOME SLEEP TESTING

The American Academy for Respiratory Care (AARC) recommends that specific types of qualified personnel provide home testing equipment set-up, patient preparation, and instruction for portable and multi-channel, home sleep-testing devices as an alternative to facility-based PSG in the evaluation of obstructive sleep apnea (OSA). Examples of qualified personnel are physicians, registered polysomnographic technologists, licensed and credentialed respiratory therapists, specially trained nurses, electroneurodiagnostic technologists, or other healthcare professionals who have been competency tested by nationally recognized accreditation entities.

All home sleep testing should be interpreted by a physician who holds current certification in one of the following:

• Sleep medicine certification by the American Board of Sleep Medicine (ABSM)
• Subspecialty certification in sleep medicine by a member board of the American Board of Medical Specialties (ABMS)
• Completed residency or fellowship training in an ABMS member board-approved program and has completed all the requirements for subspecialty certification in sleep medicine (except the examination itself), but only until the time of reporting of the first examination for which the physician is eligible.
• Active staff membership at a sleep center or laboratory accredited by the AASM or the JCAHO

Portable sleep monitoring should not be used for the diagnosis of OSA in individuals with significant comorbid conditions. Also, portable sleep monitoring should not be used for the diagnostic evaluation of individuals suspected of having comorbid sleep disorders, or for the general screening of asymptomatic populations.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, adult sleep disorder testing is covered under the medical benefits of the Company’s products when medical necessity criteria listed in the medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

BILLING GUIDELINES

Current Procedural Terminology (CPT) code 95822 is considered incidental to 95808, 95810, and 95811 because an EEG is already one of the parameters performed in a multiple stage sleep test. However, an EEG can be billed separately when performing a MSLT (95805).

A split-night sleep test requires one day of monitoring or assessment and should be billed with only CPT code 95811. No other codes are necessary.

Unattended sleep disorder testing in the home should be reported with Healthcare Common Procedure Coding System (HCPCS) Level II codes.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

MEDICARE

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

References

The American Academy of Sleep Medicine (AASM). Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. [AASM Web site]. 2007. Available at: http://www.aasmnet.org/Resources/PracticeParameters/PP_Actigraphy_Update.pdf. Accessed October 2, 2009. The American Academy of Sleep Medicine (AASM). Response to Centers for Medicare & Medicaid Services proposed decision memo for continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). [AASM Web site]. January 2008. Available at: http://www.aasmnet.org/Resources/PDF/ResponsetoCMSJan.pdf. Accessed October 2, 2009. American College of Chest Physicians (ACCP). Sleep disorders center/sleep-disordered breathing laboratory: A statement of roles and responsibilities. [AACP Web site]. 2007. Available at: http://www.chestnet.org/downloads/institutes/Sleep_MedDirectorPosition.pdf. Accessed October 2, 2009. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).240.4: Continuous postive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). [CMS Web site]. 03/13/08. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=240.4&ncd_version=3&basket=ncd%3A240%2E4%3A3%3AContinuous+Positive+Airway+Pressure+%28CPAP%29+Therapy+For+Obstructive+Sleep+Apnea+%28OSA%29. Accessed October 2, 2009. Chesson AL Jr, Berry RB, Pack A, et al. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Sleep. 2003;26(7):907-913. Collop N, Anderson M, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Journal of Clinical Sleep Medicine. 2007;3(7): 737-747. Available at: http://www.aasmnet.org/JCSM/ViewAbstract.aspx?citationid=3435. Accessed October 2, 2009. Highmark Medicare Services. Local Coverage Determination (LCD). L11504: Respiratory assist devices. [CMS Web site]. Original: 10/01/99 (Revised: 09/01/09). Available at:http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11504_2009-09-01_PA_2009-09.pdf. Accessed October 2, 2009. Highmark Medicare Services. Local Coverage Determination (LCD). L11528: Positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea. [ CMS Web site]. 09/01/09. Available at: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11528&lcd_version=42&basket=lcd%3A11528%3A42%3APositive+Airway+Pressure+%28PAP%29+Devices+for+the+Treatment+of+Obstructive+Sleep+Apnea%3ADME+MAC%3ANHIC%7C%7C+Corp%2E+%2816003%29%3A. Accessed October 2, 2009. Highmark Medicare Services. Local Coverage Determination (LCD).L27530: Sleep disorders testing. [Highmark Medicare Web site]. Original: 04/01/08. (Revised: 05/28/09). Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27530-r5.html. Accessed October 2, 2009. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499-521. Morgenthaler T, Alessi C, Friedman L, et al. Standards of Practice Committee; American Academy of Sleep Medicine. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007;30(4):519-29. Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007;30(11):1445-59. Nowack WJ, Murro AM, Talavera F. Polysomnography: overview and clinical application. [emedicine Web site]. Original: 03/29/05. (Revised: 03/30/07). Available at: http://www.emedicine.com/neuro/topic566.htm. Accessed October 2, 2009. US Departrment of Health and Human Services. National Guidelines Clearinghouse (NGC): Diagnosis and treatment of obstructive sleep apnea in adults. 09/28/2009. Available at: http://www.guidelines.gov/summary/summary.aspx?doc_id=12694&nbr=006582&string=sleep+AND+study. Accessed October 2, 2009. US Departrment of Health and Human Services. National Guidelines Clearinghouse (NGC): Search: Sleep studies. [NGC Web site]. 11/10/08. Available at: http://www.guidelines.gov/search/searchresults.aspx?Type=3&txtSearch=sleep+study&num=20. Accessed October 2, 2009.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	95805, 95807, 95808, 95810, 95811, 95822 THE FOLLOWING CODE IS CONSIDERED NOT MEDICALLY NECESSARY BECAUSE IT IS AN UNATTENDED SERVICE 95806, 0203T, 0204T THE FOLLOWING CODE IS NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT 95803
ICD Procedure	N/A
ICD Diagnosis	278.01: Morbid obesity 278.02: Overweight 278.8: Other hyperalimentation 307.3: Stereotypic movement disorder 307.41: Transient disorder of initiating or maintaining sleep 307.42: Persistent disorder of initiating or maintaining sleep 307.43: Transient disorder of initiating or maintaining wakefulness 307.44: Persistent disorder of initiating or maintaining wakefulness 307.45: Circadian rhythm sleep disorder of nonorganic origin 307.46: Sleep arousal disorder 307.47: Other dysfunctions of sleep stages or arousal from sleep 307.48: Repetitive intrusions of sleep 327.00: Organic insomnia, unspecified 327.01: Insomnia due to medical condition classified elsewhere 327.09: Other organic insomnia 327.10: Organic hypersomnia, unspecified 327.11: Idiopathic hypersomnia with long sleep time 327.12: Idiopathic hypersomnia without long sleep time 327.13: Recurrent hypersomnia 327.14: Hypersomnia due to medical condition classified elsewhere 327.19: Other organic hypersomnia 327.20: Organic sleep apnea, unspecified 327.21: Primary central sleep apnea 327.23: Obstructive sleep apnea (adult) (pediatric) 327.24: Idiopathic sleep related nonobstructive alveolar hypoventilation 327.25: Congenital central alveolar hypoventilation syndrome 327.26: Sleep related hypoventilation/hypoxemia in conditions classifiable elsewhere 327.27: Central sleep apnea in conditions classified elsewhere 327.29: Other organic sleep apnea 327.30: Circadian rhythm sleep disorder, unspecified 327.31: Circadian rhythm sleep disorder, delayed sleep phase type 327.32: Circadian rhythm sleep disorder, advanced sleep phase type 327.33: Circadian rhythm sleep disorder, irregular sleep-wake type 327.34: Circadian rhythm sleep disorder, free-running type 327.36: Circadian rhythm sleep disorder, shift work type 327.37: Circadian rhythm sleep disorder in conditions classified elsewhere 327.39: Other circadian rhythm sleep disorder 327.40: Organic parasomnia, unspecified 327.41: Confusional arousals 327.42: REM sleep behavior disorder 327.43: Recurrent isolated sleep paralysis 327.44: Parasomnia in conditions classified elsewhere 327.49: Other organic parasomnia 327.51: Periodic limb movement disorder 327.52: Sleep related leg cramps 327.53: Sleep related bruxism 327.59: Other organic sleep related movement disorders 327.8: Other organic sleep disorders 333.2: Myoclonus 333.94: Restless legs syndrome (RLS) 347.00: Narcolepsy, without cataplexy 347.01: Narcolepsy, with cataplexy 347.10: Narcolepsy in conditions classified elsewhere, without cataplexy 347.11: Narcolepsy in conditions classified elsewhere, with cataplexy 359.21: Myotonic muscular dystrophy 359.29: Other specified myotonic disorder 518.83: Chronic respiratory failure 607.84: Impotence of organic origin 780.51: Insomnia with sleep apnea, unspecified 780.53: Hypersomnia with sleep apnea, unspecified 780.54: Hypersomnia, unspecified 780.55: Disruption of 24 hour sleep wake cycle, unspecified 780.56: Dysfunctions associated with sleep stages or arousal from sleep 780.57: Unspecified sleep apnea 780.58: Sleep related movement disorder, unspecified 780.59: Other sleep disturbances 786.09: Other dyspnea and respiratory abnormalities 799.01: Asphyxia 799.02: Hypoxemia
HCPCS Level II	G0398: Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation G0399: Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation G0400: Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
Revenue Codes	N/A

Cross References

Version Effective Date: 01/01/2010