CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Lab Sleep Studies Prior Authorization

This policy governs prior authorization requirements for in-lab sleep studies (polysomnography and related tests) for adults 18 and older for Blue Cross Blue Shield - Tennessee; it does not require prior authorization for home sleep studies. It applies to fully-insured members and is optional for ASO accounts.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyLab Sleep Studies Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date1/01/2022

Next Review DateN/A

Key ActionObtain prior authorization for in‑lab sleep study CPT codes for adults 18 years or older.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+age threshold

1effective month

5CPT codes listed

Coverage Criteria — Prior Authorization Applicability

Prior Authorization Applicability

Covered when meeting authorization applicability

Authorization required for in-lab adult studies: Procedure is an in-lab sleep study (polysomnography or MSLT) performed on an adult 18 years or older using one of the listed CPT codesage >= 18

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

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

CPT Codes and Coding Guidance

Covered CPT Codes (lab studies requiring prior authorization)CPTCovered

95807

Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist

Covered CPT Codes (lab studies requiring prior authorization)CPTCovered

95808

Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist

Covered CPT Codes (lab studies requiring prior authorization)CPTCovered

95810

Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyLab Sleep Studies Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date1/01/2022

Next Review DateN/A

Key ActionObtain prior authorization for in‑lab sleep study CPT codes for adults 18 years or older.

SourceLink

On This Page

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What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for in‑lab sleep studies for adults 18 years and older. This applies to the listed CPT codes for attended laboratory polysomnography and related in‑lab testing. Note: home sleep studies do NOT require prior authorization.

Prior authorization required for in‑lab studies for adults 18+ (applies to fully‑insured members; optional add‑on for ASO).
Home sleep studies do not require prior authorization.

Denial Risk

Denial Risk if Authorization Not Obtained

Prior authorization must be obtained before scheduling in‑lab sleep studies for adults 18+. If authorization is not obtained, claims for the applicable lab CPT codes may be denied.

Denial risk if prior authorization is not obtained for lab studies (adults 18+).

Documentation Required

Documentation Requirement

Document authorization decisions in the patient record and include the prior authorization number on claims and scheduling documentation. Remember that home sleep studies are exempt from prior authorization under this program.

Include authorization number on claims and encounter records.
Home studies do not require prior authorization.

Note

Provider Alert — Affected CPT Codes

Provider note: prior authorization applies to the following CPT codes when performed in a lab setting for adults 18+ — 95807, 95808, 95810, 95811, 95805. Ensure prior authorization is secured for these codes when services are in‑lab.

Affected CPT codes: 95807, 95808, 95810, 95811, 95805.

Key Definitions

Polysomnography (lab sleep study) — definition and attributes

DefinitionSimultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist.

Key attributesAttended study conducted in a lab setting with a technologist present; simultaneous multi-parameter physiologic recordings.

Relevant CPT codes95807, 95808, 95810, 95811 (see individual code descriptions for age/parameter distinctions).

Prior authorization applicabilityRequired for lab-based polysomnography for adults 18 years or older (effective 1/01/2022).

ExclusionHome sleep studies do not require prior authorization.

Multiple Sleep Latency Test (MSLT)

DefinitionRecording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.

Relevant CPT code95805

PurposeAssess physiologic sleepiness (multiple sleep latency or maintenance of wakefulness testing).

SettingPerformed in a lab setting as part of in-lab sleep testing programs subject to authorization rules for adults.

OpenPayer

Lab Sleep Studies Prior Authorization

Coverage Criteria — Prior Authorization Applicability

CPT Codes and Coding Guidance

What Providers Must Do

Key Definitions

Background and Rationale