General Diagnostic Sleep Study Coverage
Diagnostic testing is covered only when the patient has symptoms or complaints of one of the following conditions and the need for testing is supported by medical evidence, such as physical examination and laboratory findings.
ONE of the following conditions
Narcolepsy, including inappropriate sleep episodes, amnesiac episodes, or continuous agonizing drowsiness.
Obstructive sleep apnea syndrome (OSAS).
Parasomnias or abnormal sleep behavior, including bruxism, sleepwalking, or enuresis, or evaluation of a seizure disorder when the distinction between seizure activity and another sleep disturbance is uncertain.
Narcolepsy
Related diagnostic testing, including the Multiple Sleep Latency Test (MSLT) or Maintenance of Wakefulness Test (MWT), is covered when the applicable clinical symptoms are present.
ALL of the following
The patient has inappropriate sleep episodes, amnesiac episodes, or continuous agonizing drowsiness.
For narcolepsy testing, the condition is documented as severe enough to interfere with the patient's health and well-being.
Ordinarily, a maximum of two clinic sleep sessions is sufficient for diagnosis. Claims exceeding two clinic sleep sessions must be referred for medical review.
Obstructive Sleep Apnea Syndrome
Obstructive sleep apnea syndrome (OSAS) is a covered benefit.
ALL of the following
The diagnostic testing is for suspected or established obstructive sleep apnea syndrome.
A U.S. Food and Drug Administration (FDA)-approved dental orthosis, when covered, is used to treat OSAS and not for adjunctive dental purposes.
Home Sleep Testing for Adult Obstructive Sleep Apnea
Home sleep testing (HST) is covered as an alternative to in-facility polysomnography (PSG) for diagnosing obstructive sleep apnea syndrome in an adult when ALL of the following criteria are met.
ALL of the following
The HST is ordered by an authorized provider acting within the scope of the provider's license.
The adult has a high pretest probability of obstructive sleep apnea, supported by clinical features, signs, or symptoms such as age, sex, body mass index, loud snoring, awakening with gasping or choking, excessive daytime sleepiness, or observed cessation of breathing during sleep.
The ordering authorized provider determines that a home portable sleep study is an appropriate alternative to in-laboratory PSG.
No significant comorbid condition exists that could affect study accuracy, including moderate-to-severe pulmonary disease, neuromuscular disease, or congestive heart failure.
ONE of the following clinical circumstances
Parasomnias and Suspected Epilepsy
Diagnostic sleep testing is covered for parasomnias or abnormal sleep behavior when evaluation is medically necessary, including when seizure activity cannot be distinguished from another sleep disturbance.
ONE of the following presentations
Parasomnia or abnormal sleep behavior, such as bruxism, sleepwalking, or enuresis.
A suspected seizure disorder or abnormal sleep behavior for which the distinction between seizure activity and another sleep disturbance is uncertain.
Facility, Referral, and Payment Conditions
Coverage and payment are subject to the following facility, referral, and outpatient-processing requirements.
ALL of the following
The patient is referred to the sleep disorder center by the attending physician, and the center maintains a record of the referral.
If the referral is not submitted with the claim, the contractor must develop for the referral.
Institutional and professional charges are for diagnostic sleep testing performed in a TRICARE-approved hospital and relate to narcolepsy, sleep apnea, impotence, parasomnia, or suspected epilepsy when the distinction between seizure activity and another sleep disturbance is uncertain.
Testing is processed and paid as an outpatient service; the patient is not considered an inpatient even if the patient arrives in the evening and leaves after testing.
Testing performed by an authorized freestanding clinic is furnished under the physician-directed clinic category.
A physician-directed clinic has a physician present to perform medical services whenever the clinic is open, each patient is under the care of a clinic physician, and non-physician services are medically supervised.
Electrosleep therapy, which applies short-duration, low-amplitude direct-current pulses to the brain through externally placed occipital electrodes to induce sleep, is considered unproven because its efficacy has not been established in the United States. Claims for electrosleep therapy must be denied.
Payment may not be made for services or supplies provided as part of or under a study, grant, or research program.
Sleep testing is not indicated for a patient whose complaint is of short duration or who does not experience functional disability during the day.
Diagnostic testing that duplicates previous testing performed by the attending physician is not covered when the previous results remain pertinent.
Payment may not be made for diagnostic sleep testing of conditions that can be diagnosed through other, more appropriate means, including drug dependency, hypersomnia, insomnia, night terrors or dream anxiety attacks, nocturnal myoclonus, restless leg syndrome, shift work and schedule disturbances, and migraine headaches.
If the patient has documented episodes of cataplexy, diagnostic testing for narcolepsy is not necessary and is not covered.
Type IV portable monitors are not covered.
A somnoplasty system for obstructive sleep apnea syndrome (OSAS) is unproven.
Sleep testing is not indicated when the complaint is of short duration or when the patient does not experience functional disability during the day.
When documented episodes of cataplexy are present, narcolepsy testing is not necessary and is therefore not covered.