1.0 CPT CODES
95805 - 95811, 95822, 95827
2.0 HCPCS 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
(US) 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
6.1.1 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.
6.1.2 The contractor
shall develop for a referral if a copy of the referral is not submitted
with the claim.
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.
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.