1. health and fitness
2. disorders
3. sleep disorders

Status
Active
Medical and Behavioral Health Policy
Section: Medicine
Policy Number: II-106
Effective Date: 04/20/2015
Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services
based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are
responsible for medical advice and treatment of patients. Members with specific health care needs should consult an
appropriate health care professional.
SLEEP DISORDER TESTING IN ADULTS
Description:
Sleep studies consist of selected diagnostic and therapeutic services
provided for sleep-related disorders. This policy addresses sleep
studies in patients who are 18 years of age or older. Sleep studies for
patients under the age of 18 years are addressed in a separate policy:
Sleep Studies/Polysomnograms in Children and Adolescents, II-128.
Definitions:
Apnea Hypopnea Index (AHI) equals the average number of
episodes of apnea and/or hypopnea per hour of sleep.
 Apnea is defined as the cessation of airflow for at least 10 seconds.
 Hypopnea is defined as a reduction in airflow equal to or greater
than 30% with an associated fall in oxygen saturation of at least 4%
or arousal. Hypopnea may also be defined as a reduction in airflow
of 50% or greater with a fall in oxygen saturation of at least 3%.
Epworth Sleepiness Scale (ESS): This is a short questionnaire
designed to be completed by patients. The purpose of the scale is to
subjectively assess severity of daytime sleepiness. The maximum
score is 24. A score of 10 or lower is considered normal.
Multiple Sleep Latency Test (MSLT) consists of physiological
measurements of sleep during a series of 20 minute naps at two-hour
intervals performed four to five times in an eight-hour period.
Maintenance of Wakefulness Test (MWT) measures the ability to
stay awake in a sleep inducing environment and is used to assess
occupational safety.
Nap Testing: Abbreviated daytime sleep studies have been proposed
for a number of conditions. One device, the PAP-NAP, is intended to
acclimate patients with complex insomnia to positive airway pressure
(PAP) devices. The device uses PAP therapy along with a type 3
monitor (described below) during 1-2 hour daytime naps with the
intention of transitioning patients with to nighttime PAP. Patients who
meet certain thresholds are referred to split-night PSG for full sleep
studies and PAP titration if indicated.
Narcolepsy: Narcolepsy is a neurological disorder that affects the
control of sleep and wakefulness. It is currently believed to be caused
by a deficiency in hypocretin-producing neurons in the lateral
hypothalamus. It is estimated that narcolepsy affects approximately 1
in 2000 people in the U.S. People with narcolepsy experience
excessive daytime sleepiness and intermittent, uncontrollable episodes
of falling asleep during the day. These sudden sleep attacks may
occur during any type of activity at any time of the day. Narcolepsy is
also characterized by cataplexy, hypnagogic hallucinations and/or
sleep paralysis. Narcolepsy and OSA can co-occur. Therefore, testing
for OSA is important in the workup of narcolepsy.
Obesity hypoventilation syndrome may coexist with obstructive
sleep apnea (OSA) and other sleep-disordered breathing patterns. It
is generally defined as awake hypoventilation (arterial carbon dioxide
tension [PaCO2] greater than 45 mmHg in a patient with a body mass
index greater than 30 kg/m2) without comorbid conditions that may
influence breathing function such as pulmonary or neuromuscular
disease.
Obstructive sleep apnea (OSA): A diagnosis of OSA syndrome is
accepted when an adult patient has an AHI greater than 5 and
symptoms of excessive daytime sleepiness or hypertension. It is
estimated that approximately 20% of adults have at least mild OSA,
defined as an AHI or respiratory disturbance index (RDI) of 5-15
respiratory events per hour of sleep. In adults, an AHI or RDI equal to
or greater than 15 is typically considered moderate OSA, while an AHI
or RDI greater than 30 is considered severe OSA. An estimated 7% of
adults have moderate or severe OSA.
Parasomnia: Disruptive sleep disorders that occur during arousals
from rapid eye movement (REM) sleep or partial arousals from nonREM sleep. Parasomnias include but are not limited to confusional
arousals, sleep walking, sleep terrors, nightmare disorder, sleep
paralysis, and sleep related eating disorder.
Polysomnography (PSG) is a detailed overnight sleep study that
takes place under supervision of a medical professional in a facilitybased sleep center. PSG includes recording of electrographic
variables [electroencephalogram (EEG), electrooculogram (EOG), and
submental electromyogram (EMG)] that permit identification of sleep
and its various stages; ventilatory variables that permit the
identification of apneas and their classification as central or
obstructive; arterial oxygen saturation by ear or finger oximetry; and
heart rate. Other parameters of sleep, such as extremity muscle
activity, continuous blood pressure monitoring, and body position
changes, may be recorded as needed. PSG is distinguished from other
sleep studies by the inclusion of EEG, EOG, and EMG for the
determination of sleep stage. Full night PSG refers to testing that takes
place throughout the night. Split-night PSG is defined below.
Positive Airway Pressure Devices
 Continuous Positive Airway Pressure (CPAP) involves the
administration of air, usually through the nose, by an external device
at a fixed pressure to maintain the patency of the upper airways.
 Bi-level positive airway pressure (BiPAP) is similar to CPAP, but
these devices are capable of generating two adjustable pressure
levels.
 Auto-adjusting CPAP (APAP) adjusts the level of pressure based on
the level of resistance. As a result, the device may administer a
lower mean level of positive pressure during the night. APAP is not
intended to diagnose OSA, but may be used to initiate and titrate
CPAP in adult patients with clinically significant OSA.
Respiratory Disturbance Index (RDI): may be defined as the
number of apneas, hypopneas, and respiratory event related arousals
(RERAs) per hour of sleep. It may be referred to along with or instead
of AHI particularly in unattended sleep studies.
Split-night PSG: A split-night study is one in which the initial
diagnostic PSG is followed by CPAP titration on the same night. A
split-night study followed by CPAP during the second half of the study
may eliminate the need for a second study to titrate CPAP.
Unattended Portable Sleep Studies have been developed to
evaluate sleep disorders in an effort to substitute for the more costly
facility-based PSG. Generally, these studies are not supervised by a
technician during testing. Monitors are classified into four different
categories based on the data recorded.
 Type I - facility-based PSG;
 Type II - Records a minimum of 7 channels: EEG, EOG, EMG,
ECG/heart rate, airflow, respiratory effort and oxygen saturation;
 Type III - Records a minimum of 4 channels: 2 respiratory
movement/airflow, 1 ECG/heart rate and 1 oxygen saturation;
 Type IV - Records a minimum of 3 channels.
With the development of additional protocols for assessing OSA, the
American Academy of Sleep Medicine (AASM) guidelines recommend
that equipment used outside the setting of a sleep center must provide
an RDI based on measures that approximate an AHI based on full
PSG. Equipment must also simultaneously record oxygen saturation,
heart rate, airflow, and respiratory effort.
Policy:
I.
UNATTENDED PORTABLE SLEEP STUDY – INITIAL STUDY
A single unattended portable sleep study (performed on either
one night or consecutive nights) in the home or clinic setting
with a Type II or III device (minimum of 4 recording channels
including oxygen saturation, respiratory movement, ECG or
heart rate and airflow) may be considered MEDICALLY
NECESSARY under the following circumstances:
A. Performed under the supervision of a physician and
interpreted by a physician who is either a diplomate of the
American Board of Sleep Medicine, a recognized
subspecialty of the American Board of Medical Specialties
(ABMS), or an active staff member of a sleep center or
laboratory accredited by the American Academy of Sleep
Medicine (AASM) or The Joint Commission;
AND
B. Patient meets ALL of the following:
1. Habitual snoring and/or observed apneas;
AND
2. Excessive daytime sleepiness evidenced by an Epworth
Sleepiness Scale score greater than 10 or sleepiness that
interferes with daily activities and is not explained by other
conditions;
AND
3. Patient has no evidence by history or physical
examination of a health condition that might alter
ventilation or require alternative treatment, including any
of the following:
a. Central sleep apnea
b. Congestive heart failure
c. Moderate to severe chronic pulmonary disease
d. Pulmonary hypertension
e. Obesity hypoventilation syndrome
f. Narcolepsy
g. Parasomnia
h. Periodic limb movements in sleep
i. Restless legs syndrome
j. Neuromuscular disease
k. Seizure disorder
OR
C. Patient is scheduled for bariatric surgery and has no evidence
by history or physical examination of a health condition that
might alter ventilation or require alternative treatment as
described in I.B.3.
II.
UNATTENDED PORTABLE SLEEP STUDY – REPEAT STUDY
A single unattended portable sleep study (performed on either
one night or consecutive nights) in the home or clinic setting with
a Type II or III device (minimum of 4 recording channels including
oxygen saturation, respiratory movement, ECG or heart rate and
airflow) may be considered MEDICALLY NECESSARY under
the following circumstances:
A. Performed under the supervision of a physician and
interpreted by a physician who is either a diplomate of the
American Board of Sleep Medicine, a recognized
subspecialty of the American Board of Medical Specialties
(ABMS), or an active staff member of a sleep center or
laboratory accredited by the American Academy of Sleep
Medicine (AASM) or The Joint Commission;
AND
B. One of the following:
1. To assess efficacy of surgery or oral appliances/devices;
OR
2. To re-evaluate the diagnosis of OSA and need for
continued CPAP. Examples include significant change in
weight or change in symptoms suggesting that CPAP
should be re-titrated or possibly discontinued.
III. POLYSOMNOGRAPHY – INITIAL STUDY
Attended polysomnography performed in a sleep laboratory may
be considered MEDICALLY NECESSARY as a diagnostic test in
patients with:
A. Previous home study that was technically inadequate for a
patient with signs/symptoms that indicate a high index of
suspicion of obstructive sleep apnea (i.e., habitual snoring
and/or observed apneas with excessive daytime sleepiness
evidenced by an Epworth Sleepiness Scale score greater
than 10 or sleepiness that interferes with daily activities and is
not explained by other conditions);
OR
B. Observed apneas during sleep;
OR
C. Obesity hypoventilation syndrome;
OR
D. Symptoms characteristic of narcolepsy;
OR
E. Patient meets the following criteria:
1. At least two of the following:
a. Excessive daytime sleepiness evidenced by an
Epworth Sleepiness Scale greater than 10 or
sleepiness that interferes with daily activities and is
not explained by other conditions
b. Habitual snoring or gasping/choking episodes
associated with awakening
c. Documented systemic hypertension
d. A body mass index greater than 35 kg/m2
e. Craniofacial or upper airway soft tissue abnormalities
AND
2. One or more of the following:
a. Moderate or severe congestive heart failure;
b. Stroke/transient ischemic attack;
c. Coronary artery disease or significant tachycardia or
bradycardic arrhythmias;
d. Pulmonary hypertension;
e. Prior to scheduled bariatric surgery;
f.
Patient has evidence by history or physical
examination of a health condition that might alter
ventilation or require alternative treatment, including
any of the following:
 Central sleep apnea
 Moderate to severe chronic pulmonary disease
 Parasomnia
 Periodic limb movements in sleep
 Restless legs syndrome
 Neuromuscular disease
 Seizure disorder
IV. POLYSOMNOGRAPHY – REPEAT STUDY
A. Polysomnography may be considered MEDICALLY
NECESSARY in patients who meet criteria for an inlaboratory PSG, when performed to initiate and titrate positive
airway pressure (PAP) when:
1. Split-night PSG on the initial study did not allow for the
resolution of the vast majority of obstructive respiratory
events during positive airway pressure titration;
AND
2. One of the following is present:
a. AHI or RDI on initial PSG is 15 or greater;
OR
b. AHI or RDI on initial PSG is between 5 and 14 with any
of the following associated symptoms:
 Excessive daytime sleepiness
 Documented hypertension
 Ischemic heart disease
 History of stroke
B. Subsequent attended PSG following a course of treatment
may be considered MEDICALLY NECESSARY:
1. To assess efficacy of treatment (e.g., CPAP, oral
appliances, surgery);
OR
2. To re-evaluate the diagnosis of obstructive sleep apnea
and need for continued CPAP. Examples include
significant change in weight or change in symptoms
suggesting that CPAP should be re-titrated or possibly
discontinued;
OR
3. Failure of resolution of symptoms or recurrence of
symptoms during treatment.
V. MULTIPLE SLEEP LATENCY TESTING (MSLT)
MSLT is considered MEDICALLY NECESSARY:
A. In patients with symptoms characteristic of narcolepsy
including cataplexy, hypnagogic hallucinations and/or sleep
paralysis when the individual being evaluated has excessive
daytime sleepiness (e.g. Epworth Sleepiness Scale greater
than 10) characterized by inappropriate daytime napping of
greater than 3 months duration;
AND
OSA has been ruled out after a PSG has been performed and
interpreted;
OR
B. OSA has been diagnosed and symptoms of narcolepsy persist
despite adequate treatment with positive airway pressure
therapy.
VI. INVESTIGATIVE INDICATIONS
The following are considered INVESTIGATIVE due to a lack of
evidence demonstrating improved health outcomes.
A. Unattended sleep studies for all indications not listed in
sections I and II including but not limited to the following:
1. Unattended portable sleep studies with a Type IV device or
any device that does not record RDI/AHI and also
simultaneously record oxygen saturation, heart rate and
respiratory analysis.
2. Overnight pulse oximetry
3. Diagnostic audio recording to screen patients for sleep
apnea
B. Abbreviated daytime sleep study (e.g. PAP-NAP) as a
supplement to standard sleep studies
C. MSLT for all other indications not listed in section V including
but not limited to the following:
1. Use of portable MSLT performed in the home setting
2. For initial evaluation and diagnosis of OSA
3. Assessing the effectiveness of therapy
4. Evaluation of patients who are suspected of having
excessive sleepiness due to insomnia, circadian rhythm
disorders, periodic limb movement disorder, medical
disorders or neurologic disorders other than narcolepsy.
D. Maintenance of wakefulness testing (MWT) for evaluation,
diagnosis or assessment of response to therapy for OSA.
Documentation
Submission:
The following documentation may be requested:
1. For initial unattended portable sleep studies, documentation of
the following from the physician supervising the test:
a. Signs/symptoms of sleep apnea; and
b. Verification that there are no conditions present that would
alter ventilation or require alternative treatment as
described in policy statement IB3.
2. For repeat unattended portable sleep studies, documentation
of indications for the repeat test included in policy statement
IIB from the physician supervising the test.
3. For initial or repeat attended PSG, documentation supporting
the medical necessity of the test as outlined in policy
statements under III and IV.
4. For multiple sleep latency testing:
a. Documentation of signs/symptoms of narcolepsy; AND
b. Documentation that PSG has been performed and:
 Interpretation indicates OSA has been ruled out; OR
 Documentation of treatment duration with positive
pressure airway therapy if symptoms persist in patients
with OSA and suspected narcolepsy.
Coverage:
The performance of multiple nights of an unattended portable sleep
study will be reimbursed as one service regardless of the number of
multiple nights of patient data obtained to successfully and
appropriately complete testing.
Blue Cross and Blue Shield of Minnesota medical policies apply
generally to all Blue Cross and Blue Plus plans and products. Benefit
plans vary in coverage and some plans may not provide coverage for
certain services addressed in the medical policies.
Medicaid products and some self-insured plans may have additional
policies and prior authorization requirements. Receipt of benefits is
subject to all terms and conditions of the member’s summary plan
description (SPD). As applicable, review the provisions relating to a
specific coverage determination, including exclusions and limitations.
Blue Cross reserves the right to revise, update and/or add to its
medical policies at any time without notice.
For Medicare NCD and/or Medicare LCD, please consult CMS or
National Government Services websites.
Refer to the Pre-Certification/Pre-Authorization section of the Medical
Behavioral Health Policy Manual for the full list of services,
procedures, prescription drugs, and medical devices that require Precertification/Pre-Authorization. Note that services with specific
coverage criteria may be reviewed retrospectively to determine if
criteria are being met. Retrospective denial of claims may result if
criteria are not met.
Coding:
The following codes are included below for informational purposes
only, and are subject to change without notice. Inclusion or exclusion
of a code does not constitute or imply member coverage or provider
reimbursement.
CPT:
95800 Sleep study, unattended, simultaneous recording; heart rate,
oxygen saturation, respiratory analysis (e.g., by airflow or peripheral
arterial tone), and sleep time
95801 Sleep study, unattended, simultaneous recording; minimum of
heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow
or peripheral arterial tone)
95805 Multiple sleep latency or maintenance of wakefulness testing,
recording, analysis and interpretation of physiological measurements
of sleep during multiple trials to assess sleepiness
95806 Sleep study, unattended, simultaneous recording of, heart rate,
oxygen saturation, respiratory airflow, and respiratory effort (e.g.,
thoracoabdominal movement)
95807 Sleep study, simultaneous recording of ventilation, respiratory
effort, ECG or heart rate, and oxygen saturation, attended by a
technologist
95808 Polysomnography; any age, sleep staging with 1-3 additional
parameters of sleep, attended by a technologist
95810 Polysomnography; age 6 years or older, sleep staging with 4 or
more additional parameters of sleep, attended by a technologist
95811 Polysomnography; age 6 years or older, sleep staging with 4 or
more additional parameters of sleep, with initiation of continuous
positive airway pressure therapy or bilevel ventilation, attended by a
technologist
HCPCS:
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
Policy History:
Developed August 13, 1985
Most recent history:
Revised May 9, 2012
Reviewed June 12, 2013
Revised August 14, 2013
Revised August 13, 2014
Revised February 11, 2015
Cross
Reference:
Treatment Of Obstructive Sleep Apnea and Snoring in Adults, IV-07
Sleep Studies/Polysomnograms in Children and Adolescents, II-128
Actigraphy, II-127
Current Procedural Terminology (CPT®) is copyright 2014 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative values, or
related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
Copyright 2015 Blue Cross Blue Shield of Minnesota.