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    v1.0.28
    OpenPayerPolicy UpdatesSleep MedicineBaylor Scott & White Health Plan OSA Coverage Upda…
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    CurrentBaylor Scott & White Health PlanPolicy 110

    Obstructive Sleep Apnea: Diagnosis and Treatment

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    Defines medical necessity criteria for diagnostic testing (laboratory and home PSG), indications for treatment modalities (PAP, oral appliances, surgery, hypoglossal nerve stimulation), follow-up testing, exclusions of specific therapies/devices, and applicable billing codes for obstructive sleep apnea across lines of business.

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    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyObstructive Sleep Apnea: Diagnosis and Treatment
    Policy CodePolicy 110
    Change TypeUpdated screening tooladministrative criteria removal
    Effective DateMay 1, 2026
    Last ReviewApr 23, 2026
    Next Review DateApr 23, 2027
    Key ActionDiagnostic testing for obstructive sleep apnea does NOT require prior authorization; document history/physical, a sleep questionnaire (e.g., STOP-BANG), and discussion of therapeutic options to support testing.
    SourceLink
    POLICY UPDATE CHANGES

    04/23/2026 - Updated recommended screening tool and updated references.

    08/11/2025 - Removed statement that 'Medicare NCD or LCD specific InterQual criteria may be used when available.'

    2AHI thresholds specified
    3Home sleep study device types allowed (2/3/4)
    9CPT/HCPCS codes listed as covered examples
    9Codes listed as not covered/investigational

    Coverage Summary

    This policy addresses diagnostic and treatment options for obstructive sleep apnea (OSA), defining when testing and therapies are considered medically necessary. It states that polysomnography (PSG) is the gold-standard diagnostic test for OSA and that home sleep testing (home PSG/portable monitoring of Types 2–4) is permitted as an alternative for selected patients (e.g., those with a high pretest probability of moderate to severe OSA and meeting specified criteria). The policy also clarifies that snoring alone is not a disease, and treatment for snoring without OSA is not considered medically necessary.

    Surface thresholds and scope-level summary
    AHI thresholds> 5/hour with symptoms or comorbidities; OR > 15/hour
    Minimum age for home PSG>= 6 years
    Home PSG scope/typesHome PSG Types 2, 3, and 4 allowed with minimum parameter requirements
    Home PSG supervision requirementsMust be supervised by a board-certified sleep medicine practitioner and performed with a comprehensive sleep evaluation
    Doc-level scope summaryDefines medical necessity for diagnostic testing (lab and home PSG), indications for treatments (PAP, oral appliances, surgery, hypoglossal nerve stimulation), follow-up testing, exclusions of specific therapies/devices, and applicable billing codes across lines of business.

    Medical-Necessity Criteria

    Coding

    Covered/Applicable CPTCPTCovered
    42145Palatopharyngoplasty (e.g. uvulopalatopharyngoplasty, uvulopharyngoplasty)
    94660CPAP, initiation and management
    95782Sleep Medicine Testing Procedures
    95783Sleep Medicine Testing Procedures
    95800Sleep study, unattended; heart rate, oxygen saturation, respiratory analysis, sleep time
    95801Sleep study, unattended; heart rate, oxygen saturation, respiratory analysis
    95806Sleep study, unattended; heart rate, oxygen saturation, respiratory airflow, respiratory effort
    95807Sleep study; ventilation, respiratory effort, ECG, oxygen saturation, attended
    95808Polysomnography; sleep staging with 1-3 additional parameters, attended
    95810Polysomnography; sleep staging with 4 or more additional parameters, attended
    1–10 of 13
    1/2
    Covered/Applicable CPT - code notesmixed
    No codes listed
    Covered/Applicable HCPCSHCPCSCovered
    G0398Home sleep study, type II monitor, unattended
    G0399Home sleep study, type III monitor, unattended
    G0400Home sleep study, type IV monitor, unattended
    E0601CPAP device
    E0485Oral appliance prefabricated
    E0486Oral appliance, custom fabricated
    S8262Mandibular repositioning device
    S2080Laser assisted uvulopalatoplasty (Note: LAUPPP/LAUPPP-related procedures are excluded by policy as experimental/investigational)
    Covered/Applicable HCPCS - device notesmixed
    No codes listed
    CPT Not CoveredCPTNot Covered
    41512Tongue base suspension, permanent suture technique (not covered)
    41530Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session (not covered)
    CPT Not Covered - notemixedNot Covered
    No codes listed
    HCPCS Not Covered / InvestigationalHCPCSNot Covered
    C9727Insertion of implants into the soft palate; minimum of 3 implants (investigational/not covered)
    C9749Repair of nasal vestibular lateral wall stenosis with implant(s) (investigational/not covered)
    K1028Power source and control electronics unit (investigational/not covered)
    K1029Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply (e.g., eXciteOSA) — considered experimental/investigational and not covered
    HCPCS Not Covered - devices/procedures excludedmixedNot Covered
    No codes listed
    ICD-10 Diagnosis Codes (examples provided)ICD-10
    E66.2Obesity Hypoventilation Syndrome
    F10.182Sleep disorder related to alcohol
    F10.282Sleep disorder related to alcohol
    F10.982Sleep disorder related to alcohol
    F11.182Sleep disorder related to opioid
    F11.282Sleep disorder related to opioid
    F11.982Sleep disorder related to opioid
    F13.182Sleep disorder related to anxiety
    F13.282Sleep disorder related to anxiety
    F13.982Sleep disorder related to anxiety
    1–10 of 30
    1/3
    ICD-10 notemixed
    No codes listed

    Provider Actions & Billing

    Prior Authorization

    Prior authorization for diagnostic testing

    Diagnostic testing for obstructive sleep apnea does NOT require prior authorization. Some interventions (for example, certain devices or procedures) do require prior authorization per the member's plan or EOC/SPD; verify plan-specific prior authorization requirements before billing or scheduling those interventions.

    Documentation Required

    Clinical documentation required for testing

    Document a history and physical that identifies sleep-related symptoms and any upper airway anatomic findings. Include a completed sleep evaluation questionnaire (such as STOP-BANG), documentation of potential therapeutic options discussed with the patient, any compliance concerns, and patient education provided by the sleep laboratory.

    Documentation Required

    Background & Evidence

    Full-night, attended, in-laboratory Polysomnography (PSG) is identified as the preferred and gold-standard diagnostic study for suspected OSA, with split-night PSG described for combined diagnostic and CPAP titration use. The policy permits home PSG (Types 2–4) in place of facility-based testing when specific conditions are met (e.g., patient ≥ 6 years old, supervised by a board-certified sleep medicine practitioner, performed with a comprehensive sleep evaluation, used for patients with a high pretest probability of moderate to severe OSA, and not appropriate for patients with significant comorbidities that may degrade accuracy). Home device requirements are specified by type: Type 2 = minimum seven parameters; Type 3 = minimum four parameters including two respiratory channels and one cardiac channel; Type 4 = minimum three parameters including pulse oximetry. The policy also notes exclusions: certain diagnostic/treatment modalities (for example, actigraphy for OSA diagnosis) and specific procedures (for example, laser assisted uvulopalatopharyngoplasty [LAUPPP] and other listed therapies) are considered experimental, investigational, or not medically necessary and are excluded from coverage. Additionally, the policy reiterates that snoring without OSA is not a disease and treatment for isolated snoring is not a covered benefit.

    Evidence and Background

    Unsupported block type: list

    Definitions

    Unsupported block type: definition

    Unsupported block type: definition

    Unsupported block type: definition

    Unsupported block type: definition

    Unsupported block type: definition

    Medicare Determinations

    NameNumber/Type
    Sleep Testing for Obstructive Sleep Apnea (OSA)240.4.1 (NCD)
    Continuous Positive Airway Pressure (CPAP)240.4 (NCD)
    Outpatient Sleep StudiesL35050 (LCD)
    Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep ApneaL38385 (LCD)

    Revision History

    08/11/2025updated

    Removed statement that 'Medicare NCD or LCD specific InterQual criteria may be used when available.' (Administrative/criteria sourcing change.)

    04/23/2026revisedLatest

    Updated recommended screening tool and updated references. (Policy history notes update: 'Updated recommended screening tool, updated references'.)

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyObstructive Sleep Apnea: Diagnosis and Treatment
    Policy CodePolicy 110
    Change TypeUpdated screening tooladministrative criteria removal
    Effective DateMay 1, 2026
    Last ReviewApr 23, 2026
    Next Review DateApr 23, 2027
    Key ActionDiagnostic testing for obstructive sleep apnea does NOT require prior authorization; document history/physical, a sleep questionnaire (e.g., STOP-BANG), and discussion of therapeutic options to support testing.
    SourceLink
    On This Page
    Coverage SummaryMedical-Necessity CriteriaCodingProvider Actions & BillingBackground & EvidenceMedicare DeterminationsRevision History

    Home PSG supervision requirement

    For home PSG codes G0398, G0399, and G0400: the study must be supervised by a practitioner with board certification in sleep medicine, performed in conjunction with a complete and comprehensive sleep evaluation, and is appropriate only for patients aged 6 years and older.

    Billing Rule

    Device and procedure coverage constraints

    Coverage constraints: oral appliances must be custom made/fit (not over-the-counter) to be considered medically necessary. Devices/procedures designated experimental, investigational, or not medically necessary (listed in policy) must not be billed for coverage.

    • E0486
    • E0485
    • K1029
    • C9727
    • C9749
    • S2080
    Documentation Required

    Follow-up PSG indications

    When requesting follow-up polysomnography (CPT codes 95810, 95811, 95807, 95808), document the specific clinical reason for the follow-up study (for example, lack of improvement after surgery, following placement of an oral appliance, need for initial titration when split-night or auto-titration was not possible, or CPAP re-titration for persistent/worsening symptoms) to support medical necessity.