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    v1.0.30
    OpenPayerPolicy UpdatesSleep MedicineAmbetter Nevada PSG/HNS Policy Update Coverage | O…
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    CurrentAmbetter NevadaPolicy CP.MP.248

    Facility-based Sleep Studies for Obstructive Sleep Apnea

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    Criteria, coding, and references related to facility-based polysomnography for evaluation and titration in adults with suspected or confirmed obstructive sleep apnea; applies to Ambetter Nevada members and providers following Health Plan medical necessity guidance.

    Policy Summary
    PayerAmbetter Nevada
    PolicyFacility-based Sleep Studies for Obstructive Sleep Apnea
    Policy CodePolicy CP.MP.248
    Change TypeCriteria additions, revisions, and removals (includes HNS titration)
    Effective Date
    Last ReviewOct 25, 2025
    Next Review Date
    Key ActionObtain and document indications per revised criteria (including hypoventilation syndrome, habitual loud snoring, and hypertension) and seek authorization when titration PSG for HNS is planned.
    SourceLink
    POLICY UPDATE CHANGES

    Added I.B.8.a.vi 'Hypoventilation syndrome'.

    Updated I.B.8.b.ii to 'Daytime sleepiness...'.

    Removed I.B.8.b.iv 'Significant oxygen desaturation...'.

    Added Criteria I.B.8.b.ii.c) which states, 'Diagnosis of hypertension.'

    Added Criteria IV. to include titration PSG for hypoglossal nerve stimulation (HNS).

    multipledocument revision entries summarized

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    35+
    references listed
    HNStitration PSG added

    Coverage Criteria and Indications

    Revised and added indications for PSG/HSAT and HNS titration

    Policy criteria updated; specific items added, revised, or removed within sections I and IV related to facility PSG/HSAT use and the addition of titration PSG for hypoglossal nerve stimulation (HNS).

    I.B.8.a.vi: Hypoventilation syndrome added as an indication requiring documentation

    I.B.8.b.ii

    • I.B.8.b.ii.a: Habitual loud snoring
    • I.B.8.b.ii.c: Diagnosis of hypertension

      New subcriterion added to support consideration of PSG/HSAT

    I.B.8.b.i: Epworth Sleepiness Scale requirement removed from this subcriterion (no longer required)
    I.B.8.b.iv: Removed: 'Significant oxygen desaturation...' is no longer part of criteria
    Criteria IV (Titration PSG for HNS): Added criteria to include titration polysomnography for hypoglossal nerve stimulation (HNS)

    Titration PSG for HNS added to policy and may require authorization

    The policy text has removed the former subcriterion I.B.8.b.iv that referenced "Significant oxygen desaturation...". This element is no longer part of the coverage criteria and should not be relied upon for medical necessity determinations or prior authorization decisions.

    The Epworth Sleepiness Scale requirement previously listed under I.B.8.b.i has been removed from the criteria. The policy no longer requires an Epworth score for that item; clinicians should follow the remaining documented criteria elements and provide supporting clinical documentation rather than relying on a mandatory Epworth Sleepiness Scale value.

    Coding — CPT/HCPCS and Related Rules

    CPT codes that do not support coverageCPTNot Covered
    No codes listed
    Criteria threshold additions — inv-05
    Added criterionI.B.8.b.ii.c: Diagnosis of hypertension was added as a discrete criterion element.
    Removed requirementEpworth Sleepiness Scale requirement removed from I.B.8.b.i; no longer required for that criterion.
    Other threshold editsI.B.8.b revised wording to 'Daytime sleepiness...' with addition of I.B.8.b.ii.a 'Habitual loud snoring'.

    Provider Actions, Documentation, and Authorization

    Prior Authorization

    Prior Authorization / Authorization Risk

    Prior Authorization Required: Services may require prior authorization; failure to obtain authorization when required may result in denial of payment.

    • Titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS) has been added to the policy and may require authorization or specific documentation.
    • Non‑Medicare members: see Criteria V. for any additional documentation or authorization requirements.
    Documentation Required

    Documentation and Criteria Adherence

    Documentation is required to substantiate that all clinical criteria are met. Incomplete or missing documentation (for example, failure to document hypoventilation syndrome where indicated, or absence of documentation supporting daytime sleepiness, habitual loud snoring, or comorbid conditions) may lead to claim denial or delay.

    • Include clinical notes, diagnostic test results (HSAT or PSG reports), and problem list entries supporting diagnoses such as hypoventilation syndrome, congestive heart failure, chronic pulmonary disease, or other interfering disorders.

    Background and Policy Context

    Background language and the criteria were updated to explicitly include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS). Criteria IV was added to address PSG performed to titrate or optimize HNS therapy, and the policy background was revised to reflect this addition. Providers should be aware that titration PSG for HNS is now a covered indication within the policy framework and may be subject to the usual documentation and authorization requirements.

    Definitions and Terminology

    Hypoventilation syndrome — inv-11
    New diagnosis addedI.B.8.a.vi: 'Hypoventilation syndrome' was added and requires documentation when present.
    Documentation updateI.B.8.a was updated to include 'documentation' language to support added diagnoses.
    Related editsSeveral I.B.8 elements were revised (e.g., I.B.8.a.i, I.B.8.a.ii, I.B.8.a.v) alongside the addition of hypoventilation syndrome.
    Titration PSG (HNS) — inv-12
    New criteria sectionCriteria IV added to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS).
    Background updatePolicy background updated to include information regarding titration PSG for HNS and related clarifying language in criteria.
    Policy Summary
    PayerAmbetter Nevada
    PolicyFacility-based Sleep Studies for Obstructive Sleep Apnea
    Policy CodePolicy CP.MP.248
    Change TypeCriteria additions, revisions, and removals (includes HNS titration)
    Effective Date
    Last ReviewOct 25, 2025
    Next Review Date
    Key ActionObtain and document indications per revised criteria (including hypoventilation syndrome, habitual loud snoring, and hypertension) and seek authorization when titration PSG for HNS is planned.
    SourceLink
    On This Page
    Coverage Criteria and IndicationsCoding — CPT/HCPCS and Related RulesProvider Actions, Documentation, and AuthorizationBackground and Policy ContextDefinitions and Terminology
  1. When applicable, include documentation of daytime sleepiness, habitual loud snoring, and diagnosis of hypertension per updated criteria I.B.8.b.ii and I.B.8.b.ii.a/b/c.
    2. Documentation Required

    Supportive Clinical Documentation

    Supportive clinical documentation must be provided to show indications and prior treatment efforts per the policy criteria.

    • Document prior conservative therapies and responses (e.g., CPAP trial, oral appliance, positional therapy) when required by the criteria.
    • For HNS titration PSG requests, include the HNS implantation and device information, prior PSG/HSAT results used to establish eligibility, and the recommended titration protocol.
    • Include clinician specialty (e.g., sleep medicine, pulmonology, ENT) and relevant consult notes when indicating complex comorbid conditions.
    Step Therapy

    Step Therapy and Prior Treatment

    Step Therapy / Prior Treatment Requirements: Some indications require stepwise treatment documentation before advanced procedures or devices are covered. Failure to document completion of required prior therapies may result in denial.

    • Where the criteria reference stepwise management (e.g., conservative measures followed by CPAP or alternate therapies), provide dates, duration, and objective response to each step.
    • If step therapy is applicable to HNS candidacy, include documentation of intolerance or nonresponse to CPAP and other indicated prior treatments per policy criteria.
    ReferencesLocal coverage determination and clinical references for HNS and titration PSG cited in the bibliography (see policy references).