ModifiedCentenePolicy CP.MP.248

Facility-based Sleep Studies for Obstructive Sleep Apnea

Medical necessity criteria for facility-based PSG, split-night studies, CPAP/BiPAP titration, repeat PSG, and titration PSG for hypoglossal nerve stimulation for non‑Medicare Centene plans; applies to members/enrollees aged ≥18 years.

Policy Summary

PayerCentene

PolicyFacility-based Sleep Studies for Obstructive Sleep Apnea

Policy CodePolicy CP.MP.248

Change TypeAdded HNS titration criteriarevisions and clarifications to titration and HSAT guidance

Effective Date

Next Review Date

Key ActionObtain prior authorization documenting medical necessity and indication when requesting facility-based PSG, split-night studies, or titration PSG for hypoglossal nerve stimulation.

SourceLink

POLICY UPDATE CHANGES

Added criteria section IV to include titration PSG for hypoglossal nerve stimulation (HNS).

Revised criteria III.B by removing requirement to meet criteria for facility-based sleep study and rewording failed APAP trial statement.

Clarified in I.B.5 note that HSAT has decreased sensitivity in the presence of low pretest probability of OSA and added mission-critical workers and BMI ≥50 as factors favoring facility testing.

Corrected I.B.8.a.i. to require either continuous, chronic nocturnal oxygen use or moderate to severe pulmonary function impairment instead of both.

Description updated to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS).

≥18applicable age

≤2repeat limit/yr

3–6mo

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Coverage Criteria — Facility-based PSG, Titration, and HNS

Initial Therapy (Facility-based PSG / Split-night study)

Initial facility-based PSG or split-night study — covered when ALL of the following are met

Initial PSG criteria (I)

HSAT not appropriate: One or more of: HSAT services not available; unable to operate/tolerate HSAT and no assistant available; previous HSAT negative or inadequate for diagnosis; previous HSAT negative or inadequate for APAP autotitration; chronic opioid use; low pretest probability of OSA (e.g., normal BMI <30, normal airway Mallampati 1–2, no snoring, normal neck circumference); mission-critical worker; BMI ≥50 kg/m2; documentation of specified comorbidities such as moderate to severe chronic pulmonary disease, congestive heart failure (NYHA III/IV), history of ventricular fibrillation or sustained VT without ICD, neurologic/neuromuscular disease, concern for non-respiratory sleep disorder(s) that interfere with HSAT, or hypoventilation syndrome
Comorbidities must be documented; see policy for examples and required signs/symptoms

Repeat/Continuation Therapy

Repeat facility-based PSG or split-night study — covered when ALL of the following are met

Repeat PSG criteria (II)

Repeat indications: One or more of: oral appliance adjusted for fit requiring efficacy assessment; change of device due to intolerance; assessment of PAP settings including continued symptoms despite adherent use (≥4 hours/night for 70% of nights over a 30-day period); significant weight loss (≥10%) in a member using PAP to determine if it can be discontinued; significant weight gain (≥10%) or recurrent symptoms to assess reinstitution of PAP; postoperative assessment after upper airway surgery; remote history of OSA not on PAP needing re-establishment of diagnosis/initiation of CPAP; new signs/symptoms after previous negative study; signs/symptoms with strong clinical suspicion when prior negative study was ≥6 months prior

Facility-based CPAP/BiPAP Titration

Facility-based titration of CPAP/BiPAP — covered when ONE of the following is met

Titration PSG criteria (III): A) Meets criteria in section I for facility-based sleep study and has not attempted a home-based study for titration of APAP; OR B) Diagnosed with OSA during HSAT and there is evidence/documentation of failure of an APAP trial (e.g., downloaded compliance data)

When applicable, documentation of a failed APAP trial (downloaded device data) is required

Hypoglossal Nerve Stimulation Titration

Titration PSG for hypoglossal nerve stimulation — covered when the following is met

HNS titration (IV): Titration PSG conducted three to six months after device implantation to objectively assess and calibrate device settings for efficacy and comfort3–6 months after implantation

Documentation should reflect indication for titration PSG when performed for hypoglossal nerve stimulation

Not Supported / Insufficient Evidence

Actigraphy

Actigraphy (V): Use of actigraphy testing alone for diagnosis of obstructive sleep apnea is insufficient due to inadequate evidence of effectiveness

Actigraphy (CPT 95803) does not support coverage as a standalone diagnostic test

Titration PSG for HNS (new criteria)

Document revisions describe updates to multiple criteria sections and addition of titration PSG criteria for HNS.

Criteria IV (Titration PSG for HNS): New criteria added to include titration polysomnography for hypoglossal nerve stimulation (HNS).

Titration PSG is specified to be performed 3–6 months post-implant; consult full policy for additional operational details and documentation requirements

Actigraphy testing (CPT 95803) is not supported as a standalone diagnostic modality for obstructive sleep apnea. The policy explicitly lists actigraphy as a CPT code that does not support coverage when used alone for OSA diagnosis.

The policy indicates there are CPT codes referenced that do not support coverage in the context of hypertension, but the specific CPT codes and explicit non‑covered conditions are not included in this excerpt. Providers should consult the full policy for the exact code listing and details.

Facility-based polysomnography (PSG) is considered not medically necessary when a home sleep apnea test (HSAT) is appropriate and available for adults with a high pretest probability of uncomplicated OSA and none of the facility‑necessitating conditions apply. HSAT is an acceptable alternative for select patients with high pretest probability of moderate to severe uncomplicated OSA provided there is no suspicion of non‑respiratory sleep disorder, no significant cardiorespiratory disease, they are not mission‑critical workers, and a qualified sleep expert is available to interpret results.

The document references CPT codes that do not support coverage; however, the explicit not‑medically‑necessary conditions tied to those CPT codes are not contained within the provided excerpt. Refer to the full policy for specific NMN language and code-level exclusions.

Coding — Covered and Non-covered Codes, Frequency

Covered CPT CodesCPTCovered

95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist.
95808	Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist.
95810	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95811	Polysomnography; 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.

Not supported / does not support coverageCPTNot Covered

95803

Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording).

CPT codes that do not support coverageCPTNot Covered

unspecified

CPT codes that do not support coverage (document references CPT codes but specific codes not included in this excerpt)

Repeat study frequency — Two or less per rolling year

Repeat study frequencyRequested study and any previous studies amount to two or less per rolling year.

Applies toMembers/enrollees ≥ 18 years when all criteria in section I.B are met and at least one repeat indication is present.

Examples of repeat indicationsOral appliance adjustment, device change due to intolerance, PAP setting reassessment with documented adherence issues, significant weight change (≥10%), postoperative assessment after upper airway surgery, need to re-establish diagnosis or reinstitute CPAP.

BMI threshold favoring facility testing — ≥ 50 kg/m2

BMI threshold favoring facility testingMember/enrollee has a BMI of ≥ 50 kg/m2 (criterion I.B.8).

Provider Actions — Prior Authorization, Documentation, and Titration Pathway

Prior Authorization

Prior Authorization Required

Prior authorization is required for facility-based polysomnography (PSG) and split-night studies (CPT 95807, 95808, 95810, 95811). Requests must document that the member has suspected obstructive sleep apnea (OSA) and that home sleep apnea testing (HSAT) is not appropriate or available per policy criteria (examples: inability to use HSAT, prior inadequate or negative HSAT, chronic opioid use, low pretest probability considerations, mission‑critical occupation, BMI ≥50 kg/m2, or specified comorbid conditions). If HSAT is appropriate and available, HSAT should be used instead of a facility-based PSG.

Prior authorization required for facility-based PSG and split-night studies: CPT 95807, 95808, 95810, 95811.
Document suspected OSA and rationale why HSAT is not appropriate (examples: inability to use HSAT, prior inadequate HSAT, chronic opioid use, low pretest probability, mission‑critical occupation, BMI ≥50, relevant cardiopulmonary/neurologic comorbidities).
If facility-based PSG is requested but none of the facility‑necessitating conditions are met and HSAT is appropriate and available, HSAT should be used instead.

Prior Authorization

Include Titration PSG for HNS in Prior Authorization

Include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS) in prior authorization requests when applicable. Titration PSG for HNS is considered medically necessary when performed three to six months after device implantation; documentation should indicate the indication for HNS titration and timing relative to implantation.

Background — OSA and Policy Context

Obstructive sleep apnea (OSA) is the most common form of sleep‑disordered breathing and is characterized by recurrent upper airway collapse leading to disrupted sleep and daytime sleepiness. Polysomnography (PSG) is the gold‑standard in‑laboratory test used for diagnosis, differentiation of other sleep disorders, and for titration of positive airway pressure. Home sleep apnea testing (HSAT) may be an appropriate, less burdensome option for select adults with a high pretest probability of uncomplicated OSA, while certain clinical features or comorbidities (e.g., significant cardiopulmonary disease, mission‑critical occupations, BMI ≥ 50 kg/m2, inability to tolerate HSAT, prior inadequate HSAT) indicate that facility‑based PSG is more appropriate. The policy also adds that titration PSG for hypoglossal nerve stimulation (HNS) is performed approximately three to six months after device implantation to optimize device settings.

Definitions — Key Testing Modalities and HNS Titration

PSG — Polysomnography (PSG)

TermPolysomnography (PSG).

DefinitionA comprehensive facility-based sleep study monitoring physiologic components such as sleep staging, respiratory flow, respiratory effort, pulse oximetry and ventilation; used for diagnosis, titration of positive airway pressure, and assessment of ongoing therapy.

FormatsCan be performed as a full-night study or a split-night study; split-night may include diagnostic monitoring followed by in-laboratory PAP titration the same night.

HSAT — Home sleep apnea testing (HSAT)

TermHome sleep apnea testing (HSAT).

DefinitionUnattended home-based sleep testing using portable monitors (type 3 preferred, type 4 also used) that measure fewer physiologic variables than PSG; appropriate for selected patients with high pretest probability of moderate to severe uncomplicated OSA when no significant comorbidities or non-respiratory sleep disorders are suspected.