ModifiedArizona Complete HealthPolicy CP.MP.248

Facility-based Sleep Studies for Obstructive Sleep Apnea

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Medical necessity criteria for facility-based polysomnography (PSG), split-night studies, and facility-based CPAP/BiPAP titration (including hypoglossal nerve stimulation titration) for adult members/enrollees, applicable to non-Medicare Arizona Complete Health plans.

Policy Summary

PayerArizona Complete Health

PolicyFacility-based Sleep Studies for Obstructive Sleep Apnea

Policy CodePolicy CP.MP.248

Change TypeCriteria additions and clarifications (HNS titration addedHSAT exceptions expandedactigraphy excluded)

Effective Date

Last ReviewOct 25, 2025

Next Review Date

Key ActionObtain prior authorization for facility-based PSG/titration (CPT 95807–95811) and document why HSAT is inappropriate when applicable.

SourceLink

POLICY UPDATE CHANGES

Added criteria section IV for titration PSG for hypoglossal nerve stimulation (HNS).

Expanded scope to explicitly include split-night studies and clarified facility-based titration criteria.

Added specific situations where HSAT is not appropriate (e.g., chronic opioid use, mission-critical workers, BMI ≥50, moderate-severe chronic pulmonary disease, NYHA class III/IV).

Specified that actigraphy testing alone is insufficient to diagnose OSA.

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ModifiedArizona Complete HealthPolicy CP.MP.248

Facility-based Sleep Studies for Obstructive Sleep Apnea

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Sign up for Arizona Complete Health Policy CP.MP.248 alerts

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Policy Summary

PayerArizona Complete Health

PolicyFacility-based Sleep Studies for Obstructive Sleep Apnea

Policy CodePolicy CP.MP.248

Change TypeCriteria additions and clarifications (HNS titration addedHSAT exceptions expandedactigraphy excluded)

Effective Date

Last ReviewOct 25, 2025

Next Review Date

Key ActionObtain prior authorization for facility-based PSG/titration (CPT 95807–95811) and document why HSAT is inappropriate when applicable.

SourceLink

POLICY UPDATE CHANGES

Added criteria section IV for titration PSG for hypoglossal nerve stimulation (HNS).

Expanded scope to explicitly include split-night studies and clarified facility-based titration criteria.

Added specific situations where HSAT is not appropriate (e.g., chronic opioid use, mission-critical workers, BMI ≥50, moderate-severe chronic pulmonary disease, NYHA class III/IV).

Specified that actigraphy testing alone is insufficient to diagnose OSA.

≥18age threshold for adult criteria

≥50BMI threshold

3-6 moHNS titration timing

≤2max studies/yr

95807-95811covered CPTs

95803not covered code

Coverage and Medical Necessity Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial PSG or split-night study (age): Member/enrollee is ≥ 18 years of age

Suspected condition: Member/enrollee has suspected obstructive sleep apnea (OSA)

HSAT not appropriate — any one qualifies

Availability/ability: Portable/HSAT services not available OR member unable to properly operate/tolerate home study equipment and no assistant available
Prior HSAT: Previous HSAT results are negative or inadequate for diagnosis OR inadequate for autotitration of APAP
Clinical risk factors: Chronic opioid use; low pretest probability (e.g., BMI <30, Mallampati 1–2, no snoring, normal neck circumference); mission-critical worker; BMI ≥50 kg/m2; documentation of moderate–severe chronic pulmonary disease; congestive heart failure NYHA class III/IV; history of ventricular fibrillation or sustained ventricular tachycardia; significant neurologic/neuromuscular disease; concern for non-respiratory sleep disorder(s) that interfere with HSAT; hypoventilation syndrome

Repeat Therapy

Covered when ALL of the following are met:

Repeat study prerequisites: All criteria in section I.B are met

Frequency limit: The requested study and any previous studies amount to two or less per rolling year≤2 per rolling year

Acceptable reasons for repeat

Oral appliance has been adjusted for fit and requires assessment of efficacy
Change of device due to intolerance of current device
Assessment of whether PAP settings need change (including continued symptoms despite adherent use: ≥4 hours/night for 70% of nights over a 30-day period)

Titration PSG

Facility-based titration is medically necessary when one of the following is met:

Titration option A: Meets criteria in section I for facility-based sleep study and has not attempted a home-based study for titration of APAP

Titration option B: Diagnosed with OSA during HSAT and there is evidence or documentation of failure of an APAP trial (e.g., downloaded compliance data)

HNS Titration

Covered when the following is met:

HNS titration timing: Facility-based titration PSG for hypoglossal nerve stimulation is conducted three to six months after device implantation3-6 months

Used to calibrate stimulation strength for efficacy and comfort.

Unsupported Tests

Actigraphy: Insufficient evidence to support the use of actigraphy testing alone for diagnosis of OSA

CPT 95803 listed as not supporting coverage.

Criteria revisions and additions

Policy criteria were revised in multiple subitems (I.B. series) and new items added; titration PSG for HNS added to Criteria IV.

Revisions and additions: Multiple criteria items were updated or added: I.B.8.a.vi (Hypoventilation syndrome) added; I.B.8.a.v wording expanded to include disorders that interfere with HSAT (e.g., parasomnias); I.B.8.b revisions (removal of Epworth Sleepiness Scale criteria and addition of habitual loud snoring and diagnosis of hypertension); Criteria II and III added/clarified for repeat studies and titration; Criteria IV added to include titration PSG for HNS; 'non-Medicare' verbiage added in Criteria V for clarification.

Full logical criteria details and minor wording changes summarized from revisions noted in the policy history.

The policy specifies that actigraphy testing alone (CPT 95803) is not supported for the diagnosis of obstructive sleep apnea. The document states there is insufficient evidence to support actigraphy as a standalone diagnostic modality for OSA because its effectiveness has not been established and the measure does not replace facility-based polysomnography or validated HSAT modalities.

The policy notes that there are CPT codes that do not support coverage and excludes those procedures from payment; specific codes referenced in the full policy are documented elsewhere in the coding section. Providers should consult the coding table in this policy for the exact list of excluded CPT codes when preparing prior authorization requests.

Facility-based polysomnography may be considered not medically necessary when a validated home sleep apnea test (HSAT) is appropriate and available. HSAT is an alternative for adult patients with a high pretest probability of uncomplicated moderate-to-severe OSA and no significant comorbid cardiorespiratory disease or suspected non‑respiratory sleep disorders (for example, no concern for narcolepsy, significant pulmonary disease, or complex sleep disorders). In such situations, HSAT is an accepted diagnostic option and facility PSG may be denied if HSAT would adequately address the clinical question.

The policy indicates that certain procedures/CPT codes are designated as not medically necessary (NMN) and therefore do not support coverage under the policy. Specific NMN conditions and the exact codes referenced are provided in the policy's coding and exclusions sections and should be reviewed when determining coverage and submitting authorizations.

Relevant CPT Codes and Limits

Covered CPT CodesCPTCovered

95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist.
95808	Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist.
95810	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95811	Polysomnography; age 6 years or older, 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.

CPT codes that do not support coverageCPTNot Covered

95803

Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording).

CPT codes referencedmixed

CPT codes that do not support coverage	Document notes existence of CPT codes that do not support coverage (specific codes not listed in provided chunks).
affected codes	Placeholder reference to codes affected by inclusion of titration PSG for HNS.

Titration PSG for HNS (referenced)mixed

affected codes

Codes referenced in association with inclusion of titration polysomnography for hypoglossal nerve stimulation (HNS); specific CPT codes not enumerated in these chunks.

Maximum facility-based studies per rolling year (repeat studies)

Maximum facility-based studies per rolling yearThe requested study and any previous studies must amount to two or less per rolling year (≤ 2)

Repeat study prerequisitesAll criteria in section I.B (initial PSG criteria) must be met before a repeat study is considered

Acceptable reasons for repeatExamples include oral appliance adjustment, device change for intolerance, reassessment of PAP settings despite adherence, significant weight change (≥10%), postoperative assessment after airway surgery, re-establishing diagnosis if remote history, or new/worsening symptoms after prior negative study

BMI threshold indicating facility testing

BMI threshold indicating facility testingMember/enrollee has a BMI of ≥ 50 kg/m2

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior authorization required for facility-based PSG and titration

Facility-based initial PSG, split-night, and titration studies (CPT 95807, 95808, 95810, 95811) require prior authorization and must meet the policy's medical necessity criteria (suspected OSA and reasons HSAT is not appropriate or other listed indications).

Applicable procedure codes: 95807, 95808, 95810, 95811

Prior Authorization

Include HNS titration PSG in prior authorization requests

Titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS) is included in the policy and is subject to the same prior authorization expectations as other facility-based titration PSGs.

HNS titration must be requested and authorized as a facility-based titration PSG (see Criteria IV).

Clinical Background

Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse during sleep that leads to intermittent hypoxemia, sleep fragmentation and resultant daytime sleepiness as well as a range of cardiopulmonary consequences. Polysomnography (PSG) is the diagnostic gold standard because it continuously measures multiple physiologic variables (including respiratory flow, respiratory effort, oximetry and ventilation) to establish diagnosis and guide therapy, including positive airway pressure titration. Home sleep apnea testing (HSAT) can be an appropriate alternative in selected high–pretest‑probability adults without significant comorbidities, but HSAT measures fewer variables and may miss mild or complex sleep disorders.

Key Definitions

PSG — Polysomnography definition

DefinitionPolysomnography (PSG) is the continuous and concurrent monitoring and recording of various physiological and pathophysiological parameters of sleep that includes physician evaluation, interpretation and dissemination

PurposePerformed to diagnose sleep disorders and evaluate response to treatments such as CPAP; used for diagnosis, PAP titration, and assessment of other sleep disorders

FormatsConducted as full-night or split-night studies; split-night allows diagnosis and immediate PAP titration the same night

HSAT — Home sleep apnea testing (type 3/4 devices)

DefinitionHome sleep apnea testing (HSAT) refers to portable sleep monitoring devices used at home, commonly classified as type 3 or type 4 devices

Device preference

Policy Updates and Review Cycle

01/24revision

Multiple criteria updates including adding 'Hypoventilation syndrome' (I.B.8.a.vi), wording changes to I.B.8.b.ii and other clarifications; references reviewed and updated; annual review.

10/24revision

Minor rewording and addition of hypertension diagnosis to I.B.8.b.ii.c; annual review and description updated to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS).

10/25revision

Policy Summary

PayerArizona Complete Health

PolicyFacility-based Sleep Studies for Obstructive Sleep Apnea

Policy CodePolicy CP.MP.248

Change TypeCriteria additions and clarifications (HNS titration addedHSAT exceptions expandedactigraphy excluded)

Effective Date

Last ReviewOct 25, 2025

Next Review Date

Key ActionObtain prior authorization for facility-based PSG/titration (CPT 95807–95811) and document why HSAT is inappropriate when applicable.

SourceLink

On This Page

Significant weight loss (≥10%) in a member using PAP to determine if it can be discontinued

Significant weight gain (≥10%) or recurrent symptoms to inform whether PAP should be reinstituted

Postoperative assessment of efficacy after upper airway surgery for OSA

Remote history of OSA not on PAP needing re-establishment of diagnosis and/or initiation of CPAP

New signs or symptoms after prior negative study suggesting OSA (e.g., weight gain with symptoms, new nocturia)

Signs, symptoms and strong clinical suspicion of OSA with a negative study at least six months prior

Use in triageBMI ≥50 is listed as one of the indications making HSAT not appropriate and supporting facility-based PSG

Applies to initial studiesIncluded among criteria for initial facility-based PSG or split-night study for adults ≥18 years

Step Therapy

Require documentation of failed APAP trial for titration after HSAT

When OSA is diagnosed by HSAT, facility-based titration is medically necessary only if there is documentation of failure of an APAP trial (for example, downloaded compliance data), or if the member meets criteria for a facility-based study and has not attempted a home-based titration.

Acceptable justification: evidence/documentation of failed APAP trial (e.g., downloaded compliance data).
Alternative pathway: no prior home-based APAP titration attempted and meets facility-based PSG criteria.

Note

Operational detail: specify study type and indication on requests

Ensure prior authorization requests clearly state the specific CPT code and indication (initial PSG, split-night, titration, or HNS titration) and reference the member’s age and suspected OSA status to expedite review.

State whether HSAT was attempted and results (if applicable).
Include which type of facility study is requested (initial, split-night, titration, HNS titration).

Documentation Required

Required documentation to support facility-based PSG requests

Document suspected OSA and one or more reasons why HSAT is not appropriate (examples include HSAT services unavailable; inability to operate/tolerate equipment; prior HSAT negative or inadequate; chronic opioid use; mission-critical worker; BMI ≥ 50 kg/m2; listed comorbid risks). For repeat studies, document that the requested study plus any prior studies total two or fewer per rolling year and include the specific repeat-study justification (e.g., device adjustment, device change for intolerance, failed APAP trial, significant weight change, postoperative assessment).

List the specific HSAT-inappropriateness reason(s) from policy I.B.1–9.
For repeats, confirm total studies ≤ 2 per rolling year and cite the repeat criterion met (see II.C.1–9).

Documentation Required

Incorporate new documentation items from recent criteria revisions

Policy revisions added explicit documentation expectations in I.B.8.a (including documentation for conditions such as hypoventilation syndrome) and other clarifying language; include any newly added supporting documentation (e.g., for hypoventilation syndrome) when applicable to the request.

If relying on newly added indications (e.g., hypoventilation syndrome), include supporting clinical documentation as described in the updated criteria.

Denial Risk

Denial risk: HSAT appropriateness and repeat-study frequency limits

Requests may be denied if HSAT is appropriate and available for the member, or if the requested repeat studies exceed two per rolling year without meeting the policy’s repeat-study criteria.

Confirm HSAT is inappropriate per I.B. reasons before requesting facility PSG.
For repeat requests, demonstrate the requested study plus prior studies are ≤ 2 per rolling year and that one of II.C.1–9 applies.

Billing Rule

Provider alert: CPT codes that do not support coverage (actigraphy)

Actigraphy (CPT 95803) is listed as not supporting coverage; include supported CPT codes (95807, 95808, 95810, 95811) in requests and avoid using CPT 95803 as the diagnostic basis for OSA.

Do not submit actigraphy (CPT 95803) alone to support diagnosis of OSA.
Use supported facility PSG codes (95807–95811) when requesting facility-based studies.

Type 3 devices are preferred over type 4 because they measure more variables (four to seven vs. one to three)

Appropriate useHSAT may be appropriate for select patients with high pretest probability of uncomplicated moderate-to-severe OSA and no significant comorbidities or suspected non‑respiratory sleep disorders

Hypoventilation syndrome — referenced indication

Reference in criteriaHypoventilation syndrome was added as an indication in the policy (I.B.8.a.vi) as a reason HSAT may be inappropriate

ContextListed among clinical risk factors and conditions that support facility-based PSG rather than HSAT

Implication for testingPresence of hypoventilation syndrome supports using facility-based PSG for comprehensive monitoring

Titration PSG for HNS — description

Definition/descriptionTitration PSG for hypoglossal nerve stimulation (HNS) is a facility-based polysomnography performed to calibrate HNS device stimulation strength for efficacy and comfort

TimingPolicy specifies HNS titration PSG is conducted three to six months after device implantation

Policy inclusionTitration PSG for HNS has been added to policy Criteria IV and is part of the medical necessity requirements for facility-based PSG/titration

Added Criteria IV to include titration PSG for HNS, added 'non‑Medicare' clarification in Criteria V, updated background and coding descriptions; annual review and approval.