1.0 CPT
PROCEDURE CODES
95805 - 95811, 95822, 95827
2.0 HCPCS
Procedure Codes
G0398, G0399
3.0 DESCRIPTION
A diagnostic sleep study is a
test that can be used to assist in the diagnosis of sleep-wake disorders
such as sleep apnea or narcolepsy. There are two types of sleep
apnea test:
• Polysomnography
(PSG) is the gold standard for diagnosing sleep-wake disorders.
PSG typically involves an overnight stay in a sleep laboratory.
Monitoring during testing includes electroencephalography (EEG),
electrooculography (EOG), chin electromyography (EMG), airflow,
blood oxygen saturation, respiratory effort, and electrocardiography
(ECG). Body position and leg EMG may also be monitored.
• Home
Sleep Study (HST) refers to an unattended/portable sleep study.
An HST is a PSG test typically furnished in the home. This test
usually involves measurement of airflow, breathing patterns, blood
oxygen levels, and possibly limb movements and snoring intensity.
4.0 POLICY
Diagnostic testing can be covered only if the
patient has the symptoms or complaints of one of the conditions
listed below:
4.1 Narcolepsy. This term refers to a syndrome
characterized by abnormal sleep tendencies, including excessive
daytime sleepiness, disturbed nocturnal sleep and pathological manifestation
of Rapid Eye Movement (REM) sleep. The most typical REM sleep manifestations
are cataplexy and sleep-onset REM periods, but sleep paralysis and
hypnagogic hallucinations may also be present. Related diagnostic
testing (e.g., Multiple Sleep Latency Test (MSLT) or
Maintenance of Wakefulness Test (MWT)) is covered
if the patient has inappropriate sleep episodes, amnesiac
episodes, or continuous agonizing drowsiness.
4.2 Impotence. Effective February 1, 1988.
4.3 Obstructive Sleep Apnea Syndrome
(OSAS) is a covered
benefit. A United States (U.S.) Food
and Drug Administration (FDA) approved dental orthosis may be covered
for the treatment of OSAS. The device must be used for the treatment
of OSAS and not for adjunctive dental.
4.4 Parasomnias or abnormal sleep behavior, such
as bruxism, sleepwalking, enuresis, and seizure disorder evaluations
when the distinction between seizure activity and other forms of
sleep disturbances is uncertain. Effective February 3, 1991.
5.0 Home Sleep Testing (HST)An HST is covered
as an alternative to in-facility PSG for the diagnosis of OSAS in
an adult when ALL of the following criteria are met:
5.1 When ordered
by an authorized provider acting within the scope
of his/her license.
5.2 When the patient meets all of the following
criteria:
• High
pretest probability of OSAS as evidenced
by clinical features, signs and symptoms (e.g., age, sex, Body Mass
Index (BMI), loud snoring, awakening with gasping or choking, excessive
daytime sleepiness, observed cessation of breathing during sleep);
• The ordering authorized
provider determines a home portable sleep study is
an appropriate alternative to in-laboratory PSG;
• No significant co-morbid
conditions exist that could impact the accuracy of the study (e.g., moderate
to severe pulmonary disease, neuromuscular disease, congestive heart
failure);
And
either:
• No
sleep disorders other than OSAS are
suspected (e.g., central sleep apnea, periodic limb movement disorder,
insomnia, parasomnias, circadian rhythm disorders, narcolepsy);
or
• Diagnosis
of OSAS has been established, therapy
has been initiated, and response to treatment is to be evaluated.
5.3 When the following type of portable monitor
is used:
• Type
II monitor with a minimum of seven channels (e.g., EEG
and EOG for sleep staging, ECG, chin EMG,
airflow, breathing/respiratory effort, and oxygen saturation.
• Type III monitor with
a minimum of four monitored channels including ventilation or airflow
(at least two channels of respiratory movement or respiratory movement
and airflow), heart rate or ECG, and oxygen saturation.
• Type IV monitors will
not be covered.
5.4 When the portable monitor has been validated
in a typical home environment.
5.5 When test results are reviewed and interpreted
by a physician board eligible/board certified in sleep medicine.
5.6 All testing must be performed using an FDA
approved portable monitoring device.
6.0 POLICY CONSIDERATIONS
6.1 Referral by Attending Physician. The patient
must be referred to the sleep disorder center by the attending physician,
and the center must maintain a record of the attending physician’s
referral. If a copy of the referral is not submitted with the claim,
the contractor must develop for a referral.
6.2 Diagnostic Testing. The need for diagnostic
testing is confirmed by medical evidence, e.g., physical examinations
and laboratory tests.
6.3 For narcolepsy there must be documentation
that the condition is severe enough to interfere with the patient’s
health and well-being. Ordinarily, a maximum of two clinic sleep
sessions is sufficient for diagnosis. Claims in excess of two clinic
sleep sessions must be referred to the contractor’s medical review.
6.4 Claims for diagnostic sleep studies shall be
processed and paid as outpatient services. Patients who undergo
the testing are not considered inpatients, although they may come
to the facility in the evening for testing and then leave after
their tests are over.
6.5 Institutional and professional charges related
to sleep diagnostic testing performed in a TRICARE-approved hospital
are covered only for narcolepsy, sleep apnea, impotency, parasomnia,
and suspected epilepsy when the distinction between seizure activity
and other forms of sleep disturbances is uncertain on an outpatient
cost-sharing basis.
6.6 Authorized-Freestanding Clinics. Payment may
be made for sleep diagnostic testing performed by a freestanding
clinic under the “physician-directed clinic” category.
Note: A “physician-directed clinic” is one where (a)
a physician (or a number of physicians) is present to perform medical
(rather than administrative) services at all times the clinic is
open; (b) each patient is under the care of a clinic physician;
and (c) the non-physician services are under medical supervision.
7.0 EXCLUSIONS
7.1 Electrosleep Therapy. Electrosleep therapy
is the application of short duration, low-amplitude pulses of direct
current to the patient’s brain by externally placed occipital electrodes.
Passage of the weak electric current through the tissues of the
head induces sleep. This modality is considered unproven, as its
efficacy has not been established in the U.S.
Claims for electrosleep therapy must, therefore, be denied.
7.2 Study, Grant, or Research Programs. Payment
may not be made for any services or supplies provided as a part
of or under a grant or research program.
7.3 Sleep testing is not indicated for patients
whose complaint is of short duration or for patients who do not
experience functional disability during the day.
7.4 Diagnostic testing that is duplicative of previous
testing done by the attending physician, to the extent the results
are still pertinent, is not covered.
7.5 Payment may not be made for diagnostic sleep
testing of the conditions listed below. These conditions can be
diagnosed through other, more appropriate means:
• Drug dependency
• Hypersomnia (pathologically
excessive sleep)
• Insomnia
• Night terrors or
dream anxiety attacks
• Nocturnal myoclonus
(muscle jerks)
• Restless leg syndrome
• Shift work and
schedule disturbances
• Migraine headaches
7.6 If the patient has had documented episodes
of cataplexy, diagnostic testing for narcolepsy would not be necessary
and is, therefore, not covered.
7.7 Somnoplasty system for OSAS is
unproven.
8.0 Effective
DAte
Home/portable sleep studies for the
diagnosis of OSAS in adults who meet
certain criteria are covered, effective May 29, 2008.