ModifiedBlue Cross Blue Shield - MainePolicy C-09009

Sleep Studies and Related Bundled Services and Supplies - Professional and Facility

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Reimbursement policy governing payment for polysomnography, unattended/home sleep studies, split-night studies, and related bundled services and supplies for Blue Cross Blue Shield - Maine members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicySleep Studies and Related Bundled Services and Supplies - Professional and Facility

Policy CodePolicy C-09009

Change TypeOperational revisionsbilling and facility applicability updates

Effective DateNov 1, 202640d

Last ReviewJun 10, 2026

Next Review DateN/A

Key ActionBill unattended/home sleep studies on CMS-1500 (professional) claim form; UB-04 claims will be denied except where state exemptions apply.

SourceLink

POLICY UPDATE CHANGES

Updated policy to apply to facility providers (policy previously professional-only).

Unattended and/or home sleep studies are considered professional services and should only be billed on CMS-1500 forms.

Added state-specific exemptions for Colorado, Maine, and Wisconsin.

>=3sleep staging parameters required for polysomnography

7-dayepisode window (frequency limit)

1 unitmax reimbursable unit

first threerequired staging included

Pages: 6document length

Coverage Criteria and Billing Rules

Coverage criteria and billing rules — General

General coverage and billing stance for polysomnography and unattended/home sleep studies.

Related services and supplies for professional providers performing polysomnography and other sleep studies are not eligible for separate reimbursement unless provider, state, or federal contracts and/or requirements indicate otherwise.

Polysomnography requires that sleep be recorded and staged; all polysomnography services must include the first three sleep staging parameters (frontal, central, and occipital EEG leads; left and right EOG; submental EMG). The appropriate CPT code is determined based on how many additional measured sleep parameters are recorded.

Unattended/home sleep studies are considered professional services and must be billed on a CMS-1500 claim form; UB-04 billing is not allowed for these services except where state-specific exemptions apply (see policy).

Frequency limit for unattended/home sleep study code group (95800, 95801, 95806, G0398, G0399, G0400): one (1) unit of service per seven (7) day episode beginning on the first day of testing. Modifiers will not override the frequency limit edit.

Inclusion or exclusion of a specific code in the policy does not guarantee reimbursement in all circumstances; modifiers will not override denials for bundled services and/or supplies listed in the policy.

State exemptions (examples)

Colorado: policy does not apply to facility providers and does not disallow reimbursement of unattended/home sleep studies billed on a UB-04 form.
Wisconsin: Anthem allows reimbursement of unattended/home sleep studies when billed on a UB-04 form.

Coverage criteria and billing rules — Governance, authorization, and legal

Coverage and reimbursement are governed by member benefits, medical necessity, authorization requirements, and applicable law; the policy guides claims submission but does not guarantee payment.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence.

Claims must be billed using appropriate CPT, HCPCS, and/or revenue codes and fully supported in the medical record and/or office notes.

Consequences if guidelines not followed: If appropriate coding/billing guidelines or current reimbursement policies are not followed, the payer may reject or deny the claim, or recover and/or recoup claim payment.

This reimbursement policy may be superseded by provider, state, federal, or CMS mandates; the payer reserves the right to review and update policies periodically and to recoup payments to the effective date if necessary.

Unless otherwise noted, reimbursement policies apply to both participating and nonparticipating professional providers and facilities.

Coding, Frequency Limits, and Billing Guidance

Unattended/home sleep study codesCPTCovered

95800	Home sleep study codes listed as part of unattended/home sleep study group
95801	Home sleep study codes listed as part of unattended/home sleep study group
95806	Unattended/home sleep study related code included in frequency limit
G0398	Unattended/home sleep study related code included in frequency limit
G0399	Unattended/home sleep study related code included in frequency limit
G0400	Unattended/home sleep study related code included in frequency limit

Billing codes guidancemixed

No codes listed

Unattended/home study frequency limit

Frequency limit1 unit per 7-day episode (episode begins on the first day of testing); when multiple nights of unattended/home testing occur within the 7-day period, only one unit is eligible for reimbursement.

Codes affectedApplies to unattended/home sleep study code group: 95800, 95801, 95806, G0398, G0399, G0400.

Modifier policyModifiers will not override the frequency limit edit.

Episode startThe seven-day episode begins with the first day of testing.

Provider Billing and Authorization Actions

Billing Rule

Bill unattended/home studies on CMS-1500; UB-04 not allowed except state exemptions

Unattended/home sleep studies are considered professional services and must be billed on a CMS-1500 (professional) claim form; UB-04 claims will not be allowed except where specific state exemptions apply (e.g., Colorado, Wisconsin).

Only one unit is eligible per 7-day episode regardless of multiple nights (frequency limit applies to codes 95800, 95801, 95806, G0398, G0399, G0400).
Modifiers will not override the UB-04 billing restriction or the frequency limit edit.

Prior Authorization

Ensure authorization and medical necessity for the procedure and diagnosis

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; coverage and reimbursement remain subject to the member's benefit plan terms.

Use proper billing and submission guidelines and industry-standard compliant codes (CPT, HCPCS, revenue codes).
Documentation must support billed services in the medical record and/or office notes.

Denial Risk

Noncompliance can lead to rejection, denial, or recovery/recoupment

Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and the payer may recover and/or recoup claim payment.

Ensure claims use supported CPT/HCPCS/revenue codes and that billed services are fully documented.
Policies may be superseded by provider, state, federal, or CMS mandates; review applicable mandates to avoid adverse claim actions.

Definitions

Continuous Positive Airway Pressure (CPAP) Device

DefinitionA noninvasive method, typically involving a nasal mask or flow‑generator system delivering continuous single air pressure through the nostrils to assist the patient with nocturnal respiration.

Typical useTherapeutic treatment for obstructive sleep apnea delivered during sleep.

Device componentsGenerally includes a flow generator and nasal mask interface.

Polysomnography

DefinitionA sleep test in which physiological parameters are continuously and simultaneously recorded for at least a 6‑hour period performed in a sleep laboratory with an attending technologist or qualified health care professional.

SettingPerformed in a sleep laboratory with an attending technologist or qualified health care professional.

Minimum durationAt least a 6‑hour recording period.

Sleep Staging / Additional parameters of sleep

Core sleep staging parametersFrontal, central, and occipital EEG leads (3 leads); left and right EOG; submental EMG.

Additional physiologic measuresMay include ECG, oxyhemoglobin saturation (SpO2), nasal and/or oral airflow, respiratory effort, and bilateral anterior tibialis EMG.

PurposeDelineation of distinct sleep levels by simultaneous evaluation of the listed physiologic measures.

Unattended

DefinitionA recording session during which a technologist or qualified health care professional is not physically present with the patient.

Billing implicationUnattended/home studies are considered professional services and should be billed on CMS‑1500 (not UB‑04) except where state exemptions apply.

Frequency relationUnattended/home testing nights within a 7‑day episode are subject to the one‑unit frequency limit.

Billing codes

Code systemsServices should be billed with Current Procedure Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes.

Documentation requirementWhen billed, codes must be fully supported in the medical record and/or office notes.

Inclusion caveatInclusion or exclusion of a specific code does not guarantee eligibility for reimbursement under all circumstances.

Use of Reimbursement Policy

Legal and benefit limitsThis policy is subject to federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service.

Policy evolutionReimbursement policies may be reviewed and updated periodically and may be superseded by provider, state, federal, or CMS mandates.

Payment determinationCoverage under this policy does not guarantee reimbursement; services must also meet authorization and medical necessity requirements.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicySleep Studies and Related Bundled Services and Supplies - Professional and Facility

Policy CodePolicy C-09009

Change TypeOperational revisionsbilling and facility applicability updates

Effective DateNov 1, 202640d

Last ReviewJun 10, 2026

Next Review DateN/A

Key ActionBill unattended/home sleep studies on CMS-1500 (professional) claim form; UB-04 claims will be denied except where state exemptions apply.

SourceLink

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Sleep Studies and Related Bundled Services and Supplies - Professional and Facility

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Maine Policy C-09009 alerts

Get alerted when Policy C-09009 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage Criteria and Billing Rules

Coverage criteria and billing rules — General

General coverage and billing stance for polysomnography and unattended/home sleep studies.

State exemptions (examples)

Colorado: policy does not apply to facility providers and does not disallow reimbursement of unattended/home sleep studies billed on a UB-04 form.
Wisconsin: Anthem allows reimbursement of unattended/home sleep studies when billed on a UB-04 form.

Coverage criteria and billing rules — Governance, authorization, and legal

Coverage and reimbursement are governed by member benefits, medical necessity, authorization requirements, and applicable law; the policy guides claims submission but does not guarantee payment.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence.

Claims must be billed using appropriate CPT, HCPCS, and/or revenue codes and fully supported in the medical record and/or office notes.

Unless otherwise noted, reimbursement policies apply to both participating and nonparticipating professional providers and facilities.

Coding, Frequency Limits, and Billing Guidance

Unattended/home sleep study codesCPTCovered

95800	Home sleep study codes listed as part of unattended/home sleep study group
95801	Home sleep study codes listed as part of unattended/home sleep study group
95806	Unattended/home sleep study related code included in frequency limit
G0398	Unattended/home sleep study related code included in frequency limit
G0399	Unattended/home sleep study related code included in frequency limit
G0400	Unattended/home sleep study related code included in frequency limit

Billing codes guidancemixed

No codes listed

Unattended/home study frequency limit

Codes affectedApplies to unattended/home sleep study code group: 95800, 95801, 95806, G0398, G0399, G0400.

Modifier policyModifiers will not override the frequency limit edit.

Episode startThe seven-day episode begins with the first day of testing.

Provider Billing and Authorization Actions

Billing Rule

Bill unattended/home studies on CMS-1500; UB-04 not allowed except state exemptions

Only one unit is eligible per 7-day episode regardless of multiple nights (frequency limit applies to codes 95800, 95801, 95806, G0398, G0399, G0400).
Modifiers will not override the UB-04 billing restriction or the frequency limit edit.

Prior Authorization

Ensure authorization and medical necessity for the procedure and diagnosis

Use proper billing and submission guidelines and industry-standard compliant codes (CPT, HCPCS, revenue codes).
Documentation must support billed services in the medical record and/or office notes.

Denial Risk

Noncompliance can lead to rejection, denial, or recovery/recoupment

Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and the payer may recover and/or recoup claim payment.

Ensure claims use supported CPT/HCPCS/revenue codes and that billed services are fully documented.
Policies may be superseded by provider, state, federal, or CMS mandates; review applicable mandates to avoid adverse claim actions.

Definitions

Continuous Positive Airway Pressure (CPAP) Device

Typical useTherapeutic treatment for obstructive sleep apnea delivered during sleep.

Device componentsGenerally includes a flow generator and nasal mask interface.

Polysomnography

SettingPerformed in a sleep laboratory with an attending technologist or qualified health care professional.

Minimum durationAt least a 6‑hour recording period.

Sleep Staging / Additional parameters of sleep

Core sleep staging parametersFrontal, central, and occipital EEG leads (3 leads); left and right EOG; submental EMG.

Additional physiologic measuresMay include ECG, oxyhemoglobin saturation (SpO2), nasal and/or oral airflow, respiratory effort, and bilateral anterior tibialis EMG.

PurposeDelineation of distinct sleep levels by simultaneous evaluation of the listed physiologic measures.

Unattended

DefinitionA recording session during which a technologist or qualified health care professional is not physically present with the patient.

Billing implicationUnattended/home studies are considered professional services and should be billed on CMS‑1500 (not UB‑04) except where state exemptions apply.

Frequency relationUnattended/home testing nights within a 7‑day episode are subject to the one‑unit frequency limit.

Billing codes

Code systemsServices should be billed with Current Procedure Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes.

Documentation requirementWhen billed, codes must be fully supported in the medical record and/or office notes.

Inclusion caveatInclusion or exclusion of a specific code does not guarantee eligibility for reimbursement under all circumstances.

Use of Reimbursement Policy

Legal and benefit limitsThis policy is subject to federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service.

Policy evolutionReimbursement policies may be reviewed and updated periodically and may be superseded by provider, state, federal, or CMS mandates.

Payment determinationCoverage under this policy does not guarantee reimbursement; services must also meet authorization and medical necessity requirements.