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.