CurrentBaylor Scott & White Health PlanPolicy 110

Obstructive Sleep Apnea: Diagnosis and Treatment

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.

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

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

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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

42145	Palatopharyngoplasty (e.g. uvulopalatopharyngoplasty, uvulopharyngoplasty)
94660	CPAP, initiation and management
95782	Sleep Medicine Testing Procedures
95783	Sleep Medicine Testing Procedures
95800	Sleep study, unattended; heart rate, oxygen saturation, respiratory analysis, sleep time
95801	Sleep study, unattended; heart rate, oxygen saturation, respiratory analysis
95806	Sleep study, unattended; heart rate, oxygen saturation, respiratory airflow, respiratory effort
95807	Sleep study; ventilation, respiratory effort, ECG, oxygen saturation, attended
95808	Polysomnography; sleep staging with 1-3 additional parameters, attended
95810	Polysomnography; 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

G0398	Home sleep study, type II monitor, unattended
G0399	Home sleep study, type III monitor, unattended
G0400	Home sleep study, type IV monitor, unattended
E0601	CPAP device
E0485	Oral appliance prefabricated
E0486	Oral appliance, custom fabricated
S8262	Mandibular repositioning device
S2080	Laser 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

41512	Tongue base suspension, permanent suture technique (not covered)
41530	Submucosal 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

C9727	Insertion of implants into the soft palate; minimum of 3 implants (investigational/not covered)
C9749	Repair of nasal vestibular lateral wall stenosis with implant(s) (investigational/not covered)
K1028	Power source and control electronics unit (investigational/not covered)
K1029	Oral 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

E66.2	Obesity Hypoventilation Syndrome
F10.182	Sleep disorder related to alcohol
F10.282	Sleep disorder related to alcohol
F10.982	Sleep disorder related to alcohol
F11.182	Sleep disorder related to opioid
F11.282	Sleep disorder related to opioid
F11.982	Sleep disorder related to opioid
F13.182	Sleep disorder related to anxiety
F13.282	Sleep disorder related to anxiety
F13.982	Sleep 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

Home PSG supervision requirement

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

Medicare Determinations

Name	Number/Type
Sleep Testing for Obstructive Sleep Apnea (OSA)	240.4.1 (NCD)
Continuous Positive Airway Pressure (CPAP)	240.4 (NCD)
Outpatient Sleep Studies	L35050 (LCD)
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea	L38385 (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'.)