CurrentCapital BluecrossPolicy MP 2.087

Actigraphy

This medical policy governs the use of actigraphy to assess sleep-wake patterns and body movement for sleep disorders for members of Capital Blue Cross products; it states the payer's coverage stance and coding guidance for these services.

Policy Summary

PayerCapital Bluecross

PolicyActigraphy

Policy CodePolicy MP 2.087

Change TypeAdministrative updatesclinical benefit added

Effective DateFeb 1, 2025

Next Review Date

Key ActionDo not report actigraphy separately when it is used as a component of portable sleep monitoring; consult the member's benefit plan for coverage and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Policy Guidelines updated during the 08/21/2024 consensus review with no change to the policy statement.

Clinical benefit was added during an administrative update on 01/18/2024.

Background and Rationale updated and references added on 07/11/2023 with no change to policy statement.

MP 2.087Policy identifier

1Procedure code investigational

08/21/2024Most recent consensus review

2018AASM guideline year

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Coverage Determination

Overall coverage stance

Covered only as specified; general use is investigational:

Investigational when used as sole technique: Actigraphy is considered investigational when used as the sole technique to record and analyze body movement, including use to evaluate sleep disorders.

This policy states insufficient evidence to support health outcome benefits when actigraphy is used alone (see summaries by condition).

Use within portable sleep monitoring

Not separately reportable within portable sleep monitoring: When used as a component of portable sleep monitoring, actigraphy should not be separately reported.

Policy does not address actigraphy as a component of portable monitoring beyond the reporting guidance.

Evidence summaries by condition (informational)

Evidence across conditions indicates limitations in accuracy and insufficient evidence of net health benefit:

Circadian rhythm sleep-wake disorders: Comparisons with PSG show actigraphy limited in differentiating sleep vs wake in more disturbed sleep; reliably measures sleep onset and total sleep time in some populations but does not reliably measure sleep efficiency; evidence insufficient to show net health benefit.

Source: summary of evidence.

Central disorders of hypersomnolence: Comparative observational data show low sensitivity (26.1%) and high specificity (95.5%) versus video-PSG; accuracy decreases with more disturbed sleep; not shown to improve net health outcome.

Source: summary of evidence.

Insomnia: Validation studies show poor agreement with PSG for wake time and overestimation of sleep efficiency; less effective than sleep diaries for differentiating insomnia from controls; evidence insufficient for net health benefit.

Source: summary of evidence.

Children and adolescents: Comparisons with PSG and sleep diaries show significant differences in estimation of wake and sleep times and sleep onset latency; does not reliably measure sleep efficiency; evidence insufficient for net health benefit.

Use of actigraphy as the sole technique to record and analyze body movement (including use to evaluate sleep disorders) is considered investigational. There is insufficient evidence to support a general conclusion concerning health outcomes or benefits when actigraphy is used alone.

This excerpt does not include explicit coverage criteria, exclusions, or not medically necessary statements beyond the investigational policy language and administrative history noted in the policy history.

Procedure code 95803 (actigraphy) is identified in the coding section as investigational; therefore not covered.

No explicit conditions or scenarios labeled not medically necessary are present in this excerpt of the policy.

Procedure and Billing Codes

Investigational; therefore not covered: Procedure CodesCPTNot Covered

95803

Actigraphy (investigational; therefore not covered) — Procedure Code

Provider Responsibilities and Authorization

Note

Benefit / prior authorization guidance

The existence of this medical policy does not mean that this service is a covered benefit under the member's health benefit plan. Benefit determinations should be based on the applicable health benefit plan language. Medical policies do not constitute a description of benefits. A member's health benefit plan governs which services are covered, which are excluded, which are subject to benefit limits, and which require preauthorization. Different benefit plan designs exist for each product administered by Capital Blue Cross. Members and providers should consult the member's health benefit plan for information or contact Capital Blue Cross for benefit information.

Prior Authorization

Prior authorization

No prior authorization requirements are stated in this policy excerpt. Providers should verify member-specific preauthorization requirements with Capital Blue Cross and the member's health benefit plan before rendering services.

Step Therapy

Step therapy

Background and Rationale

Actigraphy is the assessment of body movement activity patterns using a wearable device (commonly wrist-worn) that records motion during sleep and uses computer algorithms to estimate sleep and wake periods and related parameters. It provides measures such as sleep onset, total sleep duration, and wake after sleep onset by inferring sleep–wake states from movement data.

Terms and Definitions

inv-18: Actigraphy — assessment of body movement activity patterns using devices placed on the wrist, ankle, or trunk; interpreted by algorithms.

DefinitionAssessment of body movement activity patterns using devices placed on the wrist, ankle, or trunk during sleep, interpreted by computer algorithms to estimate sleep and wake periods and report parameters such as sleep onset, sleep latency, total sleep duration, and wake after sleep onset.

Typical placement and durationDevices are usually placed on the nondominant wrist (wristband) and worn continuously for at least 24 hours; activity is commonly recorded for 3 days to 2 weeks but may be collected continuously with regular data downloads.

Algorithms and settingsAlgorithms vary by device (e.g., time-above-threshold, zero-crossing, digital integration) and sensitivity settings affect detection of movement and sleep/wake classification.

Data inputs for scoringPatient bedtimes (lights out) and rise times (lights on) are usually entered from daily sleep logs or patient-activated event markers prior to analysis by proprietary software.

Alternative placements and usesMonitors may be placed on the ankle to assess restless legs syndrome or on the trunk to record movement in infants; devices can also measure general physical activity levels.

Policy Summary

PayerCapital Bluecross

PolicyActigraphy

Policy CodePolicy MP 2.087

Change TypeAdministrative updatesclinical benefit added

Effective DateFeb 1, 2025

Next Review Date

Key ActionDo not report actigraphy separately when it is used as a component of portable sleep monitoring; consult the member's benefit plan for coverage and prior authorization requirements.

SourceLink

On This Page

Source: summary of evidence.

No step therapy requirements are specified in this portion of the policy. If applicable, any step therapy controls will be defined by the member's benefit plan.

Note

No policy statement changes were made in the listed policy history entries. Administrative and consensus reviews noted 'No change to the policy statement' on multiple dates; providers should note that references and coding reviews were updated without changes to the policy statement.

MP 2.087: 07/01/2020 – Consensus Review: No change to the policy statement.
03/10/2021 – Consensus Review: No change to the policy statement.
07/12/2022 – Consensus Review: No change to policy statement.
07/11/2023 – Consensus Review: No change to policy statement.

Documentation Required

Supporting documentation for actigraphy data

Patient bedtimes (lights out) and rise times (lights on) are usually entered from daily patient sleep logs or by patient-activated event markers when actigraphy is used. Ensure that these supporting documentation elements are recorded when actigraphy data are collected as part of diagnostic evaluation or research.

Sleep logs or patient-activated event markers are commonly used to record bedtimes and rise times.
Actigraphy devices typically worn on nondominant wrist for 3 days to 2 weeks; may be continuous with regular data downloads.

Denial Risk

Investigational — denial risk

Actigraphy is considered investigational when used as the sole technique to record and analyze body movement (including its use to evaluate sleep disorders). When actigraphy is the only method used, services may be denied as investigational; coverage determinations are ultimately based on the member's benefit plan.

Actigraphy considered investigational when used alone to assess sleep disorders.
Procedure code 95803 listed as investigational/not covered in coding section.

Documentation Required

Documentation requirements

This excerpt does not contain specific documentation requirements for providers beyond routine clinical documentation and the supporting sleep logs/event markers noted above. Providers should follow member benefit plan and Capital Blue Cross administrative requirements for submission and medical record documentation.

Note

No explicit provider actions were required by policy statement changes in the excerpt. Providers should continue to verify coverage, coding, and preauthorization requirements with Capital Blue Cross and document clinical rationale and supporting data when submitting claims for actigraphy-related services.

Clinical statusActigraphy has been used in research for over two decades and is being evaluated for clinical applications in insomnia and circadian rhythm disorders; when used as the sole technique to evaluate sleep disorders it is considered investigational per this policy.

inv-19: Actigraphy — wrist-worn monitoring to measure sleep-wake patterns, validated against polysomnography in several studies and guidelines.

Wrist-worn monitoringActigraphy typically involves wrist-worn devices that measure activity to infer sleep–wake patterns and are usually worn on the nondominant wrist with a wristband.

Validation against PSGActigraphy has been validated against polysomnography in several studies and guidelines, including an AASM clinical practice guideline (2018) and device validation studies showing high conformity in some populations.

Performance limitationsAccuracy compared with polysomnography varies; actigraphy may reliably measure sleep onset and total sleep time in some populations but is limited in differentiating sleep versus wake in more disturbed sleep and in reliably measuring sleep efficiency.

Guideline referencesKey references include the AASM Clinical Practice Guideline (Smith et al., J Clin Sleep Med. 2018) and validation studies such as SOMNOwatch versus PSG (Physiol Meas. 2010).