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    v1.0.28
    OpenPayerPolicy UpdatesSleep MedicineArizona Complete Health MSLT Coverage & Prior Auth…
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    CurrentArizona Complete HealthPolicy CP.MP.24

    Multiple Sleep Latency Testing

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    Defines medical necessity criteria and coding guidance for Multiple Sleep Latency Testing (MSLT) for members/enrollees, including initial and repeat testing, and special pediatric requirements. Applies to health plans affiliated with Centene Corporation (Arizona Complete Health payer policy).

    Policy Summary
    PayerArizona Complete Health
    PolicyMultiple Sleep Latency Testing
    Policy CodePolicy CP.MP.24
    Change TypeNo material change
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization when submitting claims for CPT 95805 and document that all medical necessity criteria are met, including an overnight PSG the night before the MSLT.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≥2minimum age for covered MSLT
    ≥8 wks

    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.

    EDS duration prior to testing
    ≥10Epworth threshold
    95805referenced procedure code
    <8 min + ≥2 SOREMPsICSD-3 narcolepsy thresholds

    Coverage Criteria for MSLT

    Initial: Medically Necessary Criteria

    MSLT is medically necessary for ages two years and above when ALL of the following are met:

    Initial MSLT criteria: Member/enrollee is age ≥2 years; excessive daytime sleepiness (EDS) for ≥ eight weeks with Epworth Sleepiness Scale score ≥ 10; standard overnight PSG is planned for the night before the MSLT; suspected idiopathic hypersomnia OR suspected narcolepsy with at least one of: cataplexy (brief, sudden loss of muscle tone), hypnagogic and/or hypnopompic hallucinations, or sleep paralysis; medical conditions considered and treated if indicated; medications deemed noncontributory; no psychiatric disorder by history, or psychiatric disorder is under the care of a psychiatrist or psychologist; drug and alcohol misuse excluded; if age <11 years, consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist and testing in a facility specializing in pediatric sleep disturbances with pediatric consultants available is required.all required

    From Policy/Criteria section I

    Repeat MSLT Criteria

    Repeat MSLT is medically necessary for ages two years and above when ALL criteria in the Initial set are met AND at least ONE of the following:

    Repeat MSLT parent: Initial criteria (section I) metall required

    See section II

    Repeat MSLT triggers

    • Invalid initial test: The initial test findings are invalid or uninterpretable.
    • Extraneous circumstances: The initial test was affected by extraneous circumstances, or appropriate study conditions were not present during initial testing.
    • Clinical suspicion persists: The member/enrollee is suspected to have narcolepsy, but previous MSLT evaluation did not provide polygraphic confirmation.

    The Multiple Sleep Latency Test (MSLT) is not part of the routine evaluation for sleep disorders other than suspected narcolepsy or idiopathic hypersomnia. A diagnostic overnight polysomnogram (PSG) should be performed the night before the MSLT, and the PSG must not demonstrate significant sleep pathology (e.g., obstructive sleep apnea, central sleep apnea), because such findings would invalidate or confound MSLT results and interpretation.

    MSLT use is restricted to situations consistent with suspected idiopathic hypersomnia or suspected narcolepsy when clinical features support testing (for example, cataplexy, hypnagogic/hypnopompic hallucinations, or sleep paralysis). Testing requires documentation of excessive daytime sleepiness (EDS) for ≥ 8 weeks with an Epworth Sleepiness Scale score of ≥ 10, a planned overnight PSG the night before the MSLT, and evaluation that medical causes, medications, psychiatric conditions, and substance misuse have been considered and addressed as appropriate. MSLT results can be confounded by significant sleep pathology on prior PSG; when such pathology is present, MSLT is not an appropriate diagnostic tool.

    Coding and Diagnostic 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.
    Deleted/Informational CodesCPT
    95810Deleted/informational code for PSG (referenced as deleted in revision log).
    95811Deleted/informational code for PSG (referenced as deleted in revision log).
    Mean sleep latency / SOREMPs — ICSD-3 thresholds
    ICSD-3 diagnostic thresholdsMean sleep latency < 8 minutes AND ≥ 2 sleep-onset REM periods (SOREMPs)
    MSLT abnormal latencySleep latency < 5 minutes is distinctly abnormal and supports narcolepsy or severe sleep deprivation
    Pediatric considerationPrepubertal children may have longer latencies (8–15 minutes may suggest pathologic sleepiness)
    Epworth Sleepiness Scale — testing threshold
    Epworth thresholdEpworth Sleepiness Scale score ≥ 10
    Purpose of scoreUsed to document excessive daytime sleepiness (EDS) of sufficient severity to support MSLT consideration

    Provider Actions, Authorization & Documentation

    Prior Authorization

    Prior authorization required for CPT 95805

    Prior authorization is required for claims for CPT 95805. The prior authorization request must document that all medical necessity criteria in Section I are met, including that a standard overnight PSG is planned for the night before the MSLT.

    • CPT 95805 is the referenced procedure code for MSLT.
    Note

    Operational coordination for PSG and pediatric cases

    Ensure testing is ordered and coordinated so the MSLT is performed the day after an overnight PSG and that pediatric consults and facility capability are arranged when applicable (age <11).

    • MSLT is conducted on the day following an overnight PSG.
    • If age <11 years, a consultation with a pediatric neurologist/pulmonologist/sleep specialist and testing in a pediatric-capable facility with pediatric consultants available is required.

    Background

    The MSLT objectively measures an individual’s tendency to fall asleep by providing multiple nap opportunities across the day (typically four or five trials). It is the standard test for quantifying daytime sleepiness and is commonly used when evaluating suspected narcolepsy or idiopathic hypersomnia. Standard protocols require an overnight diagnostic PSG the night before the MSLT and use metrics such as mean sleep latency and the number of sleep-onset REM periods (SOREMPs) to aid diagnosis; pediatric interpretation may differ, and younger children often have longer mean latencies.

    Definitions

    MSLT — definition and purpose
    DefinitionMultiple Sleep Latency Test (MSLT): an objective daytime test measuring tendency to fall asleep across multiple nap opportunities to quantify sleepiness
    Standard protocolConsists of four or five 20‑minute nap opportunities at two‑hour intervals while recording EEG and other PSG‑comparable parameters
    Timing relative to PSGConducted on the day following an overnight polysomnogram (PSG) that should not show significant sleep pathology
    SOREMP — definition and diagnostic relevance
    DefinitionSleep‑onset REM period (SOREMP): occurrence of REM sleep at sleep onset during a nap opportunity
    Diagnostic relevanceTwo or more SOREMPs on the MSLT, together with mean sleep latency < 8 minutes, support a diagnosis of narcolepsy (ICSD‑3)
    Policy Summary
    PayerArizona Complete Health
    PolicyMultiple Sleep Latency Testing
    Policy CodePolicy CP.MP.24
    Change TypeNo material change
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization when submitting claims for CPT 95805 and document that all medical necessity criteria are met, including an overnight PSG the night before the MSLT.
    SourceLink
    On This Page
    Coverage Criteria for MSLTCoding and Diagnostic ThresholdsProvider Actions, Authorization & DocumentationBackgroundDefinitions
    Required documentationRecord Epworth score in clinical documentation when requesting MSLT
    Duration of symptoms — required duration of EDS
    Minimum durationExcessive daytime sleepiness (EDS) present for ≥ 8 weeks
    Documentation requirementDocument duration of EDS in clinical records to support medical necessity for MSLT
    Relation to other criteriaDuration is one of multiple required criteria for initial MSLT coverage
    Documentation Required

    Required documentation elements

    Document excessive daytime sleepiness for ≥8 weeks with an Epworth Sleepiness Scale score ≥10; document that a standard overnight PSG is planned for the night before the MSLT; and document evaluation/treatment of medical conditions, medication review, psychiatric evaluation status, and exclusion of drug/alcohol misuse. For children <11, include the required pediatric consultation and facility capability documentation.

    • EDS duration: ≥8 weeks and Epworth Sleepiness Scale ≥10.
    • Planned overnight PSG the night before MSLT.
    • Assessment and treatment of medical conditions and medication review.
    • Psychiatric disorder absent or under care; drug and alcohol misuse excluded.
    • For <11 years: pediatric specialist consultation and pediatric-capable facility documentation.
    Denial Risk

    Potential triggers for denial

    Absence of documentation that meets all required criteria may lead to claim denial — examples include insufficient duration of EDS, Epworth score below the threshold, no planned prior PSG, or unresolved medical/psychiatric contributors.

    • EDS < 8 weeks documented.
    • Epworth Sleepiness Scale score < 10.
    • No documentation that an overnight PSG is planned for the night before the MSLT.
    • Unaddressed medical conditions, contributory medications, psychiatric disorder not addressed, or unresolved drug/alcohol misuse.
    Clinical noteSOREMPs are counted across the multiple daytime nap trials included in the MSLT protocol