CurrentCentenePolicy CP.MP.24

Multiple Sleep Latency Testing (MSLT) Coverage Criteria

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Defines medical necessity criteria and coding guidance for Multiple Sleep Latency Testing (MSLT) for members/enrollees age two years and older, and requirements for repeat testing. Applies to health plans affiliated with Centene Corporation.

Policy Summary

PayerCentene

PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria

Policy CodePolicy CP.MP.24

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for CPT 95805 and submit documentation that all medical necessity criteria are met, including Epworth ≥10, EDS ≥8 weeks, and planned prior overnight PSG.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥2minimum age for coverage

≥8 wksduration of EDS required

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CurrentCentenePolicy CP.MP.24

Multiple Sleep Latency Testing (MSLT) Coverage Criteria

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Sign up for Centene Policy CP.MP.24 alerts

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Policy Summary

PayerCentene

PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria

Policy CodePolicy CP.MP.24

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for CPT 95805 and submit documentation that all medical necessity criteria are met, including Epworth ≥10, EDS ≥8 weeks, and planned prior overnight PSG.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥2minimum age for coverage

≥8 wksduration of EDS required

95805referenced procedure code

Medical Necessity Criteria for MSLT

inv-01: Initial MSLT medical necessity

Covered when ALL of the following are met:

Initial MSLT criteria (Section I): Member age ≥2 years AND excessive daytime sleepiness (EDS) for ≥ eight weeks with Epworth Sleepiness Scale score ≥ 10 AND a standard overnight polysomnography (PSG) is planned for the night before the MSLT AND suspected idiopathic hypersomnia OR suspected narcolepsy with any of: cataplexy, hypnagogic/hypnopompic hallucinations, or sleep paralysis AND medical conditions considered and treated if indicated AND medications deemed noncontributory AND no psychiatric disorder by history OR psychiatric disorder is under the care of a psychiatrist or psychologist AND drug and alcohol misuse excluded

inv-02: Pediatric (<11 years) additional requirements

For age <11, ALL of the following additional requirements must be met:

Pediatric-specific requirements: Consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist AND the MSLT ordered by that consulting physician AND testing conducted in a facility specializing in pediatric sleep disturbances with pediatric consultants available

inv-03: Repeat MSLT

Repeat MSLT is covered when ALL of Section I criteria are met AND any ONE of the following:

Repeat MSLT indications (Section II): Initial test findings are invalid or uninterpretable OR the initial test was affected by extraneous circumstances or appropriate study conditions were not present during the initial testing OR member is suspected to have narcolepsy but previous MSLT failed to provide polygraphic confirmation

The Multiple Sleep Latency Test (MSLT) is designed to objectively measure an individual's tendency to fall asleep and is a standard component of the evaluation for suspected narcolepsy or idiopathic hypersomnia. It is not part of the routine evaluation for other sleep disorders, and should not be used as a general sleep-disorder screening tool when other diagnoses are suspected.

MSLT is not medically necessary when the Section I medical necessity criteria are not met. Examples include situations where the preceding overnight polysomnogram (PSG) demonstrates significant sleep pathology (for example, obstructive sleep apnea or central sleep apnea), or when required clinical thresholds such as symptom duration, Epworth Sleepiness Scale score, age-related requirements, specialist consultation for young children, or assessment of contributing medical conditions, medications, psychiatric disorders, and substance misuse have not been satisfied.

Procedure Codes and Diagnostic Thresholds

Covered CPT CodesCPTCovered

95805

Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.

inv-07: Mean sleep latency (MSLT) — < 8 minutes (ICSD-3 narcolepsy diagnostic threshold)

Mean sleep latency thresholdMSLT mean sleep latency < 8 minutes (ICSD-3 narcolepsy diagnostic threshold)

Clinical contextRequired as part of diagnostic criteria for narcolepsy per ICSD-3 when combined with ≥2 SOREMPs

Pediatric notePrepubertal children may have longer latencies; 8–15 minutes can suggest pathologic sleepiness in younger children

inv-08: Distinctly abnormal sleep latency — < 5 minutes

Distinctly abnormal latencySleep latency < 5 minutes is distinctly abnormal and supports narcolepsy or severe sleep deprivation

ImplicationStrong objective evidence of severe daytime sleepiness on MSLT

Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required for CPT 95805 when requesting MSLT. Submit documentation that all medical necessity criteria in this policy are met prior to authorization.

CPT 95805

Note

Provider Ordering and Referral Requirements

Providers must order MSLT only after appropriate evaluation and scheduling steps are in place (see policy criteria). For children <11 years, ensure consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist and plan testing in a pediatric-specialized facility.

Documentation Required

Clinical Background and Indications

The MSLT quantifies an individual's tendency to fall asleep by providing multiple nap opportunities during the day and measuring sleep onset and REM occurrence. It is the standard objective test when suspected narcolepsy or idiopathic hypersomnia is present and is used to confirm abnormal sleepiness consistent with these conditions.

Test Description and Diagnostic Criteria

inv-16: MSLT test structure — Four or five 20-minute nap opportunities at two-hour intervals with EEG and PSG-like monitoring

Number and timing of napsFour or five nap opportunities, each 20 minutes in duration, at two-hour intervals during the day

Monitoring requirementsRecording electroencephalography (EEG) and other parameters comparable to a polysomnogram (PSG)

SchedulingMSLT is conducted the day following an overnight PSG to ensure valid results

PurposeDesigned to quantify sleepiness by measuring sleep latency across multiple trials

inv-17: SOREMP and mean sleep latency criteria — ICSD-3 requires mean sleep latency <8 minutes and ≥2 SOREMPs for narcolepsy; <5 minutes is distinctly abnormal

ICSD-3 narcolepsy criteria

Policy Summary

PayerCentene

PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria

Policy CodePolicy CP.MP.24

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for CPT 95805 and submit documentation that all medical necessity criteria are met, including Epworth ≥10, EDS ≥8 weeks, and planned prior overnight PSG.

SourceLink

On This Page

Relation to ICSD-3<5 minutes is referenced separately from the ICSD-3 mean <8-minute requirement as distinctly abnormal

inv-09: Epworth Sleepiness Scale — ≥ 10

Epworth Sleepiness Scale (ESS) thresholdESS score ≥ 10 required to meet medical necessity for MSLT

Role in criteriaUsed to quantify excessive daytime sleepiness (EDS) for ≥8 weeks in initial MSLT criteria

DocumentationESS score must be documented when requesting prior authorization for CPT 95805

inv-10: Duration of symptoms — ≥ 8 weeks

Minimum duration of symptomsExcessive daytime sleepiness present for ≥ 8 weeks is required for initial MSLT coverage

Combined requirementDuration requirement must be met along with ESS ≥10 and other Section I criteria

Repeat testingRepeat MSLT coverage still requires meeting Section I criteria, including symptom duration

Required Documentation for MSLT Authorization

Document the following when requesting authorization for MSLT: Epworth Sleepiness Scale score (≥ 10), duration of excessive daytime sleepiness (≥ eight weeks), results or plan for a standard overnight polysomnography (PSG) the night before MSLT, evaluation and treatment of contributing medical conditions, list of medications reviewed and deemed noncontributory, exclusion or management of psychiatric disorder, and exclusion of drug and alcohol misuse. For repeat MSLT, document reason (invalid/uninterpretable initial test, extraneous circumstances affecting initial test, or need for polygraphic confirmation when narcolepsy is still suspected).

Denial Risk

Denial Triggers for Not Meeting Medical Necessity

Denial may occur if medical necessity criteria are not met. Common denial triggers include: age criteria not met, insufficient duration or documentation of excessive daytime sleepiness, Epworth Sleepiness Scale score < 10, absence of a planned or completed standard PSG the night before MSLT, untreated or unaddressed contributing medical conditions, medications not reviewed or considered contributory, untreated/unstable psychiatric disorder, or unresolved drug/alcohol misuse. For repeat testing, denials may be issued if the reasons for repeat testing do not meet the policy (e.g., initial test was valid and interpretable).

Mean sleep latency < 8 minutes plus ≥ 2 sleep-onset REM periods (SOREMPs) are required for narcolepsy diagnosis per ICSD-3

Distinct abnormality thresholdA mean sleep latency < 5 minutes is considered distinctly abnormal and supports narcolepsy or severe sleep deprivation

Pediatric considerationPrepubertal children often have longer latencies; 8–15 minutes may suggest pathologic sleepiness rather than <8 minutes