CurrentCentenePolicy CP MP.24

Clinical Policy: Multiple Sleep Latency Testing

Defines medical necessity criteria for MSLT (including repeat testing) for members ages 2 years and above, required pre-test evaluations and conditions (including pediatric-specific requirements), and coding guidance referencing CPT 95805.

Policy Summary

PayerCentene

PolicyClinical Policy: Multiple Sleep Latency Testing

Policy CodePolicy CP MP.24

Change TypeClarified; Revised (annual review)

Effective Date

Next Review Date

Key ActionFor patients age < 11 years, ensure MSLT is ordered by a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist and performed in a pediatric-specialized facility; document EDS duration and Epworth score, pre-test PSG planning, medication and psychiatric evaluation, and report CPT 95805 for MSLT.

POLICY UPDATE CHANGES

Added criteria for repeat MSLT in section II (repeat testing indications).

Annual review completed; background and references updated with no impact to criteria (04/25).

1Covered CPT code

Ages 2+Eligible age range

≥8 weeksMinimum symptom duration required

Coverage Summary

Medical Necessity Criteria

I. Initial MSLT — Medically Necessary Criteria

MSLT is medically necessary for ages two years and above when ALL of the following are met:

ALL of the following

Excessive daytime sleepiness (EDS) for ≥ eight weeks, as measured by a score of ≥ 10 on the Epworth Sleepiness ScaleEpworth score ≥ 10; EDS duration ≥ 8 weeks
Standard polysomnogram (PSG) is planned for the night before the MSLT
PSG required preceding MSLT to ensure valid results
Medical conditions considered and treated, if indicated
Medications deemed noncontributory
Drug and alcohol misuse excluded
Suspected diagnoses (ONE of)
- Suspected idiopathic hypersomnia
- Suspected narcolepsy and any of the following
If suspected narcolepsy, ONE of the following features
- Cataplexy (brief, sudden loss of muscle tone)
- Hypnagogic and/or hypnopompic hallucinations
- Sleep paralysis
Psychiatric consideration (ONE of)
- No psychiatric disorder by history
- Psychiatric disorder is present but under the care of a psychiatrist or psychologist
Pediatric-specific pathway (applies if age < 11 years)
- Has had a consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist, and the MSLT has been ordered by the consulting physician
- The MSLT will be conducted in a facility specializing in pediatric sleep disturbances with pediatric consultants available

II. Repeat MSLT — Medically Necessary Criteria

Repeat MSLT is medically necessary for ages two years and above when ALL criteria from section I are met and AT LEAST ONE of the following:

ALL of the following

Member meets the criteria in section I (initial MSLT criteria)
Refer to Section I
ONE of
- The initial test findings are invalid or uninterpretable
- The initial test is affected by extraneous circumstances, or appropriate study conditions were not present during initial testing
- The member/enrollee is suspected to have narcolepsy, but previous MSLT evaluation did not provide polygraphic confirmation

Provider Actions & Documentation

Prior Authorization

Pre-test consultation requirement for pediatric patients

For patients under 11 years, the MSLT must be ordered by a consulting pediatric specialist (pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist) and the test must be performed in a facility that specializes in pediatric sleep disturbances with pediatric consultants available.

95805

Documentation Required

Required clinical documentation

Document the duration of excessive daytime sleepiness and the Epworth Sleepiness Scale score, evaluation and treatment of relevant medical conditions, a medication review showing medications are noncontributory, exclusion of drug and alcohol misuse, psychiatric assessment or documentation that psychiatric disorder is under psychiatric/psychologic care if present, and that a standard polysomnogram (PSG) is planned for the night before the MSLT.

95805

Billing Rule

Use of CPT 95805

Report CPT code 95805 for MSLT services (multiple sleep latency testing with analysis and interpretation of physiological measurements during multiple trials to assess sleepiness).

95805

Background & Evidence

MSLT consists of four or five daytime nap opportunities with EEG and other recordings on the day following an overnight PSG and is the standard objective test for suspected narcolepsy and useful for evaluating idiopathic hypersomnia. Pediatric performance differs from adults — prepubertal children often have longer sleep latencies (guidance suggests 8–15 minutes may indicate pathologic sleepiness in prepubertal children) and may require adapted protocols or extended nap opportunities. Children with suspected narcolepsy (including those as young as two years) require pediatric-specific evaluation and, for younger children, consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist and testing in a facility with pediatric sleep consultants available.

Definitions

Evidence

Revision History

2024-04-25annual_reviewLatest

Annual review completed; background updated and codes reviewed with no impact to coverage criteria (background and references updated, reviewed by external specialist).

2024-04-25clarification

Clarification added specifying repeat MSLT indications: repeat testing is medically necessary if initial test findings are invalid or uninterpretable, if the initial test was affected by extraneous circumstances or inappropriate study conditions, or if narcolepsy is strongly suspected but prior MSLT did not provide polygraphic confirmation.