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    v1.0.28
    OpenPayerPolicy UpdatesSleep MedicineAmbetter Nevada MSLT Coverage Prior Auth | OpenPay…
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    CurrentAmbetter NevadaPolicy CP.MP.24

    Multiple Sleep Latency Testing (MSLT) Coverage Criteria

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    Criteria and coding guidance for when MSLT is considered medically necessary for evaluation of suspected narcolepsy or idiopathic hypersomnia for members/enrollees of Ambetter Nevada (Centene-affiliated health plans).

    Policy Summary
    PayerAmbetter Nevada
    PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria
    Policy CodePolicy CP.MP.24
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization for MSLT (CPT 95805) when all medical necessity criteria are met and document EDS duration, Epworth score, and plan/results of prior-night PSG.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    CPT 95805referenced procedure code for MSLT
    >= 2minimum age for MSLT coverage

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    ≥ 8 wks
    required duration of EDS
    ≥ 10Epworth score threshold

    MSLT Coverage Criteria

    Initial MSLT (medically necessary criteria)

    Covered when ALL of the following are met:

    Initial MSLT coverage (Section I): Member/enrollee is >= 2 years of age; has excessive daytime sleepiness (EDS) duration >= eight weeks with Epworth Sleepiness Scale score >=10; if age <11 years, consultation with pediatric neurologist/pediatric pulmonologist/pediatric sleep medicine specialist and test ordered by that consultant and conducted in a pediatric-specialized facility with pediatric consultants available; a standard PSG is planned for the night before the MSLT; suspected idiopathic hypersomnia OR suspected narcolepsy with any of cataplexy, hypnagogic/hypnopompic hallucinations, or sleep paralysis; medical conditions considered and treated if indicated; medications deemed noncontributory; psychiatric disorder absent or under care of psychiatrist/psychologist; drug and alcohol misuse excluded.

    Repeat MSLT (medically necessary criteria)

    Repeat MSLT is covered when ALL criteria from Section I are met AND at least ONE of the following:

    Repeat MSLT prerequisite: Meets all Section I criteria
    Valid reasons for repeat MSLT (Section II): At least one of: initial test findings are invalid or uninterpretable; initial test affected by extraneous circumstances or inappropriate study conditions; strong clinical suspicion of narcolepsy but initial MSLT did not provide polygraphic confirmation.

    The MSLT is intended to objectively measure daytime sleep propensity as part of the evaluation for suspected narcolepsy or idiopathic hypersomnia. It is not part of the routine evaluation for other sleep disorders, and results can be invalidated if the prior-night polysomnogram (PSG) demonstrates significant sleep pathology such as obstructive or central sleep apnea. A diagnostic PSG should be performed the night before the MSLT and should not show significant sleep-disordered breathing to ensure valid MSLT interpretation.

    Use of the MSLT for routine evaluation of sleep disorders other than suspected narcolepsy or idiopathic hypersomnia is not supported by this policy. The test is a specialized tool for quantifying sleepiness in those specific diagnostic contexts and should not be used as a general screening or routine assessment for other sleep disorders.

    Coding and Test Thresholds

    Referenced CPT CodesCPTCovered
    95805Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.
    Epworth Sleepiness Scale score — threshold value
    Epworth Sleepiness Scale score>= 10
    Required EDS duration>= 8 weeks
    Context of useMeasured as part of criteria for MSLT medical necessity for suspected narcolepsy or idiopathic hypersomnia
    Mean sleep latency (adults) for narcolepsy
    Adult mean sleep latency< 8 minutes
    SOREMPs requirement>= 2 sleep-onset REM periods (SOREMPs)
    Diagnostic context

    Provider Requirements and Authorization

    Prior Authorization

    Prior authorization required for MSLT (CPT 95805)

    Prior authorization is required for CPT 95805 when the criteria in Section I are met, including age ≥ 2 years, EDS ≥ eight weeks with Epworth ≥ 10, a standard PSG planned for the night before the MSLT, suspected narcolepsy or idiopathic hypersomnia, consideration/treatment of medical contributors, medications deemed noncontributory, psychiatric disorder absent or under care, and exclusion of drug/alcohol misuse.

    • Applies to CPT 95805 (Multiple sleep latency testing).
    Step Therapy

    Step therapy: Not applicable

    No step therapy requirements apply for MSLT; the policy does not specify any step therapy prior to authorization or testing.

    Background

    The multiple sleep latency test (MSLT) consists of four or five 20‑minute nap opportunities at two‑hour intervals on the day following an overnight polysomnogram (PSG), with EEG and physiologic monitoring comparable to PSG. It measures how quickly a person falls asleep (mean sleep latency) and the occurrence of sleep‑onset REM periods (SOREMPs) to quantify sleepiness. In adults, a mean sleep latency of < 8 minutes plus ≥ 2 SOREMPs is required by ICSD‑3 for narcolepsy, while a sleep latency of < 5 minutes is considered distinctly abnormal. The MSLT is the standard objective test in the evaluation of suspected narcolepsy and may also be useful in assessing suspected idiopathic hypersomnia.

    Definitions and Abnormal Thresholds

    Excessive daytime sleepiness (EDS) — duration and Epworth threshold
    Duration of EDS required>= 8 weeks
    Epworth threshold for EDS>= 10 on the Epworth Sleepiness Scale
    Use caseRequired as part of initial MSLT medical necessity criteria for suspected narcolepsy or idiopathic hypersomnia
    MSLT abnormal thresholds — adult mean sleep latency and SOREMPs; distinct abnormal threshold
    Adult mean sleep latency (abnormal)< 8 minutes
    Required SOREMPs for narcolepsy>= 2 sleep-onset REM periods
    Distinctly abnormal threshold
    Policy Summary
    PayerAmbetter Nevada
    PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria
    Policy CodePolicy CP.MP.24
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization for MSLT (CPT 95805) when all medical necessity criteria are met and document EDS duration, Epworth score, and plan/results of prior-night PSG.
    SourceLink
    On This Page
    MSLT Coverage CriteriaCoding and Test ThresholdsProvider Requirements and AuthorizationBackgroundDefinitions and Abnormal Thresholds
    ICSD-3 criteria for narcolepsy require both mean sleep latency <8 minutes and >=2 SOREMPs
    Sleep latency considered distinctly abnormal
    Distinctly abnormal sleep latency< 5 minutes
    Clinical implicationSupports diagnosis of narcolepsy or severe sleep deprivation
    Testing conditionsMeasured during MSLT conducted the day after overnight PSG
    Documentation Required

    Required documentation for MSLT requests

    Document the member's duration of excessive daytime sleepiness (≥ eight weeks), the Epworth Sleepiness Scale score (≥ 10), and that a standard polysomnography (PSG) is planned for the night before the MSLT; also document evaluation/treatment of medical contributors, medication review, psychiatric status or care, and exclusion of drug/alcohol misuse.

    • Duration of EDS (≥ eight weeks) and Epworth Sleepiness Scale score.
    • Results or plan for prior-night standard PSG showing no significant sleep pathology.
    • Assessment and treatment of medical conditions and medications as noncontributory.
    • Documentation of psychiatric status (absent or under care) and exclusion of substance misuse.
    Denial Risk

    Potential denial triggers

    Requests may be denied if documentation does not show EDS for ≥ eight weeks, lacks an Epworth Sleepiness Scale score ≥ 10, or does not document a planned standard PSG the night before the MSLT.

    • Missing documentation of EDS duration (≥ eight weeks).
    • Missing Epworth Sleepiness Scale score or score < 10.
    • No documentation that a standard PSG is planned for the night before the MSLT.
    < 5 minutes considered distinctly abnormal