Polysomnography (PSG) for Non‑Respiratory Sleep Disorders
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This policy governs when attended facility-based polysomnography (PSG) and associated multiple sleep latency testing (MSLT) are considered medically necessary for evaluation of non-respiratory sleep disorders (hypersomnias, parasomnias, and sleep-related movement disorders) for members of Capital Bluecross products to which the policy applies.
No material clinical or coverage changes in this revision.
Coverage Criteria for Polysomnography and MSLT
Medically Necessary Indications
Covered when ALL of the following specific condition-based criteria are met for attended facility PSG/MSLT:
MSLT diagnostic parameters described elsewhere (mean sleep latency <5 minutes, >=2 sleep-onset REM periods for narcolepsy).
Applies to parasomnias that risk harm (e.g., violent sleepwalking, REM sleep behavior disorder).
Evaluation should include anterior tibialis EMG per policy guidance and PLMD diagnosis requires exclusion of other conditions.
Investigational / Not Medically Necessary Indications
Not covered / Investigational when ANY of the following apply:
Concurrent conditions may confound interpretation; PSG for PLMD in these cases is investigational.
There is insufficient evidence that PSG improves net health outcome for these indications.
Hypersomnia
Covered when PSG is used to evaluate suspected hypersomnia as part of diagnostic workup for narcolepsy:
Evidence considered sufficient to show meaningful improvement in net health outcome for narcolepsy diagnosis when PSG+MSLT are used.
Parasomnias
Coverage stance varies by parasomnia type:
Evidence is insufficient that PSG improves net health outcome for typical/benign parasomnias.
Evidence sufficient to determine PSG results in meaningful improvement in net health outcome for these cases.
Sleep-Related Movement Disorders
Coverage stance depends on suspected disorder:
Evidence is insufficient that PSG improves net health outcome for restless legs syndrome.
Evidence is sufficient to determine PSG improves net health outcome when used to diagnose PLMD in the appropriate context.
PSG for the diagnosis of periodic limb movement disorder (PLMD) is considered investigational when any of the following concurrent conditions are present: untreated obstructive sleep apnea; restless legs syndrome; narcolepsy; or rapid eye movement (REM) sleep behavior disorder.
Polysomnography is considered investigational for non-respiratory sleep disorder indications that do not meet the specific coverage criteria listed in this policy. Examples explicitly cited include nightmare disorder, depression, sleep-related bruxism, and noninjurious disorders of arousal.
Typical or benign parasomnias (for example, sleepwalking and sleep terrors) are generally diagnosed on clinical features and do not require PSG. Similarly, restless legs syndrome is a clinical sensorimotor diagnosis that occurs predominantly when awake and PSG is generally not useful for establishing that diagnosis.
The policy states there is insufficient evidence to conclude that PSG improves health outcomes or provides benefit for many non-respiratory sleep disorder indications. As a result, use of PSG for such indications is considered investigational per this policy.
Use of PSG for typical or benign parasomnias and for restless legs syndrome is considered not generally necessary because these conditions are often diagnosable by history and clinical evaluation and available evidence does not show PSG improves net health outcomes in these situations.
Regulatory and Diagnosis Codes
| FDA product code OLV | PSG devices regulatory product code |
| G47.11 | Idiopathic hypersomnia with long sleep time |
| G47.12 | Idiopathic hypersomnia without long sleep time |
| G47.13 | Recurrent hypersomnia |
| G47.411 | Narcolepsy with cataplexy |
| G47.419 | Narcolepsy without cataplexy |
| G47.50 | Parasomnia, unspecified |
| G47.51 | Confusional arousals |
| G47.52 | REM sleep behavior disorder |
| G47.53 | Recurrent isolated sleep paralysis |
| G47.54 | Parasomnia in conditions classified elsewhere |
| G47.59 | Other parasomnia |
| G47.61 | Periodic limb movement disorder |
Provider Actions and Billing Guidance
Confirm product-specific applicability
This policy applies only to certain Capital Blue Cross programs and products; benefit terms may vary by product (for example, FEP PPO follows the FEP Medical Policy Manual). Verify whether the member’s product is covered under this policy or requires referral to another manual before proceeding.
- FEP PPO members: refer to the FEP Medical Policy Manual at https://www.fepblue.org/…
Verify benefit-based prior authorization requirements
Coverage and any prior authorization requirements depend on the member’s benefit program; the policy lists procedure and diagnosis codes but identification of a code does not guarantee coverage. Check the member’s benefit terms to determine if prior authorization is required.
- The presence of a listed ICD-10-CM diagnosis code does not denote coverage; benefits determine coverage and separate reimbursement eligibility.
- Determine prior authorization rules from the member’s benefit program.
Use criteria for attended facility-based PSG
Use these criteria only for attended polysomnography performed in a facility setting; the policy is intended for facility-based attended PSG for the medically necessary conditions described.
- Do not apply these criteria to unattended or home sleep testing for non-respiratory disorders; those are outside the scope of this policy.
Ensure standard PSG physiologic monitoring
Perform a standard full polysomnogram recording these physiologic parameters: EEG, chin EMG, EOG, respiratory effort and airflow, oximetry, ECG, anterior tibialis EMG, and video per policy guidance.
- EEG to stage sleep and wakefulness
- Chin EMG and EOG to assess REM and muscle tone
- Respiratory measures and oximetry to assess apneic events
- Anterior tibialis EMG to detect periodic limb movements
- Video to document behaviors
Verify eligibility and benefit program terms
Verify member eligibility and the specific terms of the member’s benefit program prior to scheduling or submitting claims; medical policy determination does not guarantee payment and final claim processing depends on benefit contract and eligibility on date of service.
- Confirm member eligibility on the date of service
- Confirm benefit limitations, exclusions, and prior authorization requirements
Risk of denial for investigational indications
PSG is considered investigational (and may be denied) for non-respiratory sleep disorders that do not meet the policy’s specified criteria, including but not limited to nightmare disorder, depression, sleep-related bruxism, and noninjurious disorders of arousal.
- Avoid submitting claims or authorization requests for PSG for these indications without documenting how the case meets medically necessary criteria.
Coverage depends on member benefits, not policy codes alone
Coverage of services is determined by the member’s benefit terms; listing a procedure or diagnosis code in the policy does not guarantee coverage or separate reimbursement eligibility.
- Do not assume coverage solely because a code appears in the policy coding section.
Background
Hypersomnias (including narcolepsy and idiopathic hypersomnolence), parasomnias, and sleep-related movement disorders (restless legs syndrome and PLMD) are non-respiratory sleep disorders for which PSG may be used. PSG assesses multiple physiologic parameters to stage sleep, identify REM and NREM phenomena, record limb movements, and capture behaviors via video. When narcolepsy or idiopathic hypersomnia is suspected, PSG followed by a multiple sleep latency test (MSLT) performed the day after PSG may be medically necessary to support diagnosis. PSG is also appropriate when evaluating parasomnias that involve injurious or potentially injurious disruptive behaviors, and PSG with anterior tibialis electromyography is the diagnostic method for PLMD when other criteria are met. Conversely, PSG is investigational or not generally necessary for many other non-respiratory indications as described above.
Definitions
Policy Revision History
Removed the word 'untreated' from the statement 'No other concurrent untreated sleep disorder'; changed NMN to INV and moved notes to policy guidelines; updated policy guidelines, background, and references; no changes to coding.
Minor editorial refinements to the policy statement; updated rationale and references; no changes to coding.
Updated background and references; no changes to coding.
Background and references updated; updated ICD-10 table.
Consensus review with references updated and FEP updated; no coding changes.
Consensus review with references reviewed and updated; coding reviewed and unchanged.
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