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    v1.0.28
    OpenPayerPolicy UpdatesSleep MedicineBCBS Tennessee in‑lab Sleep Studies Prior Auth | O…
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    CurrentBlue Cross Blue Shield - TennesseePolicy N/A

    Lab Sleep Studies Program CPT List — Prior Authorization for In‑Lab Sleep Studies

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    This policy governs prior authorization requirements for in-lab sleep studies for adults (18+) for fully insured members of Blue Cross Blue Shield - Tennessee and lists the covered CPT codes. It does not require prior authorization for home sleep studies.

    Policy Summary
    PayerBlue Cross Blue Shield - Tennessee
    PolicyLab Sleep Studies Program CPT List — Prior Authorization for In‑Lab Sleep Studies
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJan 1, 2022
    Next Review DateN/A
    Key ActionObtain prior authorization for in‑lab sleep studies for adults age 18 or older.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5CPT procedure codes listed
    18+Age threshold (years)

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    1/01/2022Policy effective

    Coverage Criteria

    Authorization condition for in-lab studies

    Covered when ALL of the following are met

    In-lab study authorization: Procedure is an in-lab sleep study for an adult (age 18 or older)age >= 18

    Prior authorization required for fully-insured members; optional add-on for ASO

    Prior authorization is not required for sleep studies performed at home.

    CPT Codes for Lab Sleep Studies

    Lab sleep study CPT CodesCPTCovered
    95807Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
    95808Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
    95810Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
    95811Polysomnography; 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
    95805Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

    Provider Actions and Prior Authorization

    Prior Authorization

    Prior authorization required for listed CPT codes (lab; adults 18+)

    Prior authorization is required for the listed CPT codes when performed in a lab setting for adults 18 years or older.

    • Affected CPT codes: 95807, 95808, 95810, 95811, 95805
    Note

    Prior authorization is required for sleep studies performed in a lab setting for adults 18 years or older; prior authorization is not required for home sleep studies.

    • Program applies to fully‑insured members and is an optional add‑on for Administrative Services Only (ASO).
    Documentation Required

    Background

    Polysomnography and related in‑lab sleep studies record multiple physiologic parameters while the patient is attended by a technologist. Typical monitored measures include ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, along with additional sleep staging parameters as specified by CPT descriptors.

    Common CPT descriptions for in‑lab testing include: 95807 (sleep study with ventilation, respiratory effort, ECG/heart rate, and oxygen saturation, attended by a technologist); 95808/95810 (polysomnography with sleep staging plus additional physiologic parameters); 95811 (polysomnography with initiation of CPAP or bilevel ventilation); and 95805 (multiple sleep latency or maintenance of wakefulness testing for assessment of sleepiness).

    Procedure Definitions (CPT)

    inv-09: CPT 95807 — Polysomnography; any age, sleep staging with 1-3 additional parameters, attended by a technologist.
    CodeCPT 95807
    DescriptionSleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
    Coverage notePrior authorization required when performed in a lab setting for adults 18 years or older
    inv-10: CPT 95808 / 95810 — Polysomnography; age 6 years or older, sleep staging with 4+ additional parameters, attended by a technologist.
    CodesCPT 95808, CPT 95810
    DescriptionPolysomnography; 95808: any age, sleep staging with 1-3 additional parameters of sleep; 95810: age 6 years or older, sleep staging with 4 or more additional parameters of sleep, both attended by a technologist

    Revision History

    2022-01-01policy effective dateLatest

    Policy establishing the Lab Sleep Studies Program and CPT list became effective; prior authorization required for in‑lab sleep studies for adults 18 years and older (optional for ASO).

    Policy Summary
    PayerBlue Cross Blue Shield - Tennessee
    PolicyLab Sleep Studies Program CPT List — Prior Authorization for In‑Lab Sleep Studies
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJan 1, 2022
    Next Review DateN/A
    Key ActionObtain prior authorization for in‑lab sleep studies for adults age 18 or older.
    SourceLink
    On This Page
    Coverage CriteriaCPT Codes for Lab Sleep StudiesProvider Actions and Prior AuthorizationBackgroundProcedure Definitions (CPT)Revision History

    Authorization requirement for in‑lab studies (adults 18+)

    Providers must obtain prior authorization for in‑lab sleep studies for adults age 18 or older per the Lab Sleep Studies Program.

    • This requirement applies to fully‑insured members; ASO plans may opt in.
    Denial Risk

    Denial risk if prior authorization not obtained (in‑lab; adults 18+)

    Lack of prior authorization for in‑lab sleep studies for adults (age 18+) may lead to claim denial under this program.

    • The program applies to fully‑insured members and is optional for ASO employers — absence of authorization may result in denial for those covered under the program.
    Coverage notePrior authorization required when performed in a lab setting for adults 18 years or older
    inv-11: CPT 95811 — Polysomnography with initiation of CPAP or bilevel ventilation, attended by a technologist.
    CodeCPT 95811
    DescriptionPolysomnography; 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
    Coverage notePrior authorization required when performed in a lab setting for adults 18 years or older
    inv-12: CPT 95805 — Multiple sleep latency or maintenance of wakefulness testing for assessment of sleepiness.
    CodeCPT 95805
    DescriptionMultiple sleep latency or maintenance of wakefulness testing; recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
    Coverage notePrior authorization required when performed in a lab setting for adults 18 years or older