CurrentAmbetter NevadaPolicy CP.MP.24

Multiple Sleep Latency Testing (MSLT) Coverage Criteria

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

≥ 8 wksrequired 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

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

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Coding and Test Thresholds

Referenced CPT CodesCPTCovered

95805

Multiple 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 contextICSD-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

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.

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.

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.

OpenPayer

Multiple Sleep Latency Testing (MSLT) Coverage Criteria

MSLT Coverage Criteria

Coding and Test Thresholds

Provider Requirements and Authorization

Background

Definitions and Abnormal Thresholds