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.