If the patient meets criteria for a PSG, but one of the contraindications below is present, a facility based PSG will be allowed.ġ. A home sleep study provided in the presence of one of the contraindications below is not a covered benefit. The following are contraindications for Home Sleep Studies only. ![]() A second home sleep study may be indicated to evaluate the impact of uvulopatatopharyngoplasty (UPPP) or other corrective surgeries for OSA after appropriate recovery from surgery Home Sleep Studies (HSS) may be considered medically necessary when they are clinically indicated in the judgment of the treating physician. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered. For Commercial plans, precertification is not required, but is encouraged for out-of-network services performed in the office that are covered under the Member’s General Benefits package. Precertification is not required for Unattended/Home Sleep Testing (HST) CPT codes 95800, 95801, 95806 and HCPCS codes G0398, G0399, G0400.Ģ Actigraphy as a stand-alone test (CPT code 95803) is not medically necessary and requires Medical Director review.ģ Precertification is required for services covered under the Member’s General Benefits package when performed in the office of a participating provider. Special Considerations 1 Precertification with review by a Medical Director or their designee is required for attended/Laboratory Sleep Testing (LST), CPT codes 95805, 95807, 95808, 9581. Polysomnography/sleep studies are covered only once every five years except as noted above (II.C). CPT code 95810 is only covered as noted above (II.B.). Other measurements performed during a sleep study (e.g., vital signs, muscular activity, oximetry, airflow, blood gases, penile tumescence, gastroesophageal reflux) are also integral to the service and will not be paid separately.į. Multiple Sleep Latency Testing (CPT code 95805) will be covered for the evaluation of patients with a suspected diagnosis of narcolepsy to confirm the diagnosis.Į. Follow-up PAP titration study when indicated and split-night sleep study could not be completed as noted in II.B.ĭ. When clinical response is insufficient or when symptoms return despite a good initial response to treatment with PAP device.Ĥ. After surgical or oral appliance treatment of patients with moderate to severe OSA ģ. Weight gain or loss of ten percent of body weight Ģ. A repeat polysomnogram before five years will be covered for the following indications:ġ. One polysomnogram/sleep study will be covered every five years unless there is a significant change in patient status. CPAP trial attempted but not tolerated by patient.Ĭ. Criteria for obstructive sleep apnea met late in study with insufficient sleep time left for continuous positive airway pressure (CPAP) titration ģ. Examples include, but are not limited to, the following:Ģ. CPT code 95810 is only allowable when the sleep study does not demonstrate events consistent with sleep apnea or PAP titration cannot be completed for unforeseen reasons as documented in the polysomnography report. Polysomnography/sleep study should be performed with the intent to complete the study with titration of positive airway pressure (PAP) i.e., CPT code 95811. ![]() UnitedHealthcare Community Plan does not require prior authorization and/or advance notification for unattended sleep testing performed at home. Which sleep-related procedure codes do not require prior authorization and/or notification?Ī. 95806 – Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) – average fee amount – $170 – $180ĩ5805 – Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepinessĩ5807 – Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologistĩ5808 – Polysomnography sleep staging with 1-3 additional parameters of sleep, attended by a technologistĩ5810 – Polysomnography sleep staging with 4 or more additional parameters of sleep, attended by a technologistĩ5811 – Polysomnography 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
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