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Sleep Disordered Breathing Diagnosis and Treatment Guidelines (Coverage Policy)

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Cigna/EviCore coverage policy governing medical necessity criteria, diagnostic testing, and initial treatment considerations for sleep-disordered breathing for members of health plans administered by Cigna; applies to providers requesting sleep studies and related services.

Policy Summary

Payerevicore

PolicySleep Disordered Breathing Diagnosis and Treatment Guidelines (Coverage Policy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionOrder HSAT or PSG through a treating medical provider and ensure interpretation by a board-certified sleep medicine physician; include prior study reports and a current comprehensive clinical evaluation to support in‑lab testing when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

110document pages

2026-05-01effective date

≥15/hrOSA diagnostic threshold

≥5–<15AHI range needing symptoms

≥4 hrs/70%PAP compliance

Not coveredPAP-NAP

Coverage Criteria — Diagnostic Testing and Therapy

inv-01: General criteria for sleep diagnostic testing and when PSG is required

Coverage for diagnostic sleep testing requires documentation of a current comprehensive clinical evaluation and relevant signs/symptoms; in‑lab PSG is required for higher‑risk scenarios as specified below.

Pre-test requirements: Current comprehensive clinical evaluation by the treating medical provider (face-to-face or telehealth) documented, including comprehensive sleep history (either sleep symptoms relevant to suspected diagnosis OR sufficient history to permit completion of a validated sleep questionnaire OR results of a sleep questionnaire), physical examination, relevant prior diagnostic studies (e.g., prior sleep studies, overnight oximetry, cardiac or pulmonary testing), and relevant labs (ABG or serum bicarbonate within one year).

Questionnaire proxy: Either results of an appropriate sleep questionnaire OR history/physical elements permitting calculation of a validated questionnaire OR prior diagnosis of OSA confirmed by prior testing may satisfy the questionnaire requirement.

Clinical features raising suspicion for SDB: One or more of: unexplained excessive daytime sleepiness/fatigue impairing sleep-related quality of life; snoring/snorting/choking/gasping; witnessed apneas; awakening with breath‑holding/shortness of breath/gasping/coughing/choking; prior OSA with description of response to therapy; resistant or refractory hypertension; observed oxygen desaturations during sleep or sedation; atrial fibrillation; systolic congestive heart failure; recent stroke or TIA within 6 months; or other suggestive symptoms (nonrestorative sleep, morning headaches, nocturia, impaired concentration/memory/function).

Policy Summary

Payerevicore

PolicySleep Disordered Breathing Diagnosis and Treatment Guidelines (Coverage Policy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

SourceLink

On This Page

When PSG (in‑lab) is required instead of HSAT: PSG rather than HSAT is medically necessary when clinical evaluation raises concern for sleep‑disordered breathing AND at least one of the following is documented: validated questionnaire/history indicating need for in‑lab testing; inability to safely use HSAT due to mobility/dexterity/cognitive limitations; prior HSAT attempted and negative or technically inadequate (technically inadequate HSAT lacks minimum 4 hours of oximetry and flow data); or at least one specified comorbid diagnosis/clinical scenario is present per policy (see related criteria groups).

inv-02: Indications for in-lab PSG or in-lab PAP titration

PSG (in‑lab full night diagnostic or split‑night, or full‑night PAP titration) rather than HSAT is medically necessary when clinical evaluation raises concern for sleep‑disordered breathing AND ONE of the following applies:

Validated questionnaire or inability to complete HSAT: Results of a validated questionnaire (e.g., STOP‑BANG, Berlin) or history/physical permitting completion of such a questionnaire indicating need for in‑lab testing; OR individual lacks mobility, dexterity, or cognitive ability to safely use HSAT at home and follow instructions.

Prior HSAT inadequate or negative with ongoing concern: HSAT was attempted and is negative, or HSAT was technically inadequate (report submitted); technically inadequate HSAT lacks a minimum of 4 hours of oximetry and flow data.

Obesity with hypercapnia or OHS concern: Obesity with ONE of: BMI ≥45; BMI ≥30 plus awake ABG/EtPCO2/TcPCO2 with PCO2 ≥45 mmHg or VBG PCO2 ≥50 mmHg; OR BMI ≥30 plus serum bicarbonate ≥27 with concern for obesity hypoventilation syndrome (OHS).

Moderate to severe pulmonary disease: Nocturnal oxygen use, ABG showing PO2 <60 or PCO2 ≥45 mmHg, or pulmonary function testing showing moderate to severe obstruction (FEV1 ≤69% predicted).

Documented neurological disease: Neurological disease that precludes safe HSAT use (e.g., stroke with residual deficits) OR concern for central sleep apnea or hypoventilation (e.g., neuromuscular disease such as myotonic dystrophy or ALS).

Moderate to severe heart disease or pulmonary hypertension: Moderate to severe congestive heart failure with pulmonary congestion or LVEF <45%; OR pulmonary hypertension with mean pulmonary artery pressure >20 mmHg (RHC) or echocardiographic evidence as specified.

Chronic severe insomnia or opioid use: Chronic severe insomnia documented by validated questionnaire (ISI ≥22); OR chronic daily opioid use (daily long‑acting opioids) or daily opioid use with stated concern for central sleep apnea.

Indication for in‑lab titration/bi‑level PAP: Request for in‑lab full‑night PAP titration (bi‑level HCPCS E0470/E0471) when CPAP/APAP has been tried and proven ineffective or not tolerated, OR diagnosis of central sleep apnea (with or without Cheyne‑Stokes), treatment‑emergent central sleep apnea, neuromuscular/restrictive thoracic disease, severe COPD with awake PaCO2 ≥52 mmHg, OHS, or other hypoventilation syndromes per defined physiologic thresholds.

inv-03: Indications for in-lab PAP titration based on prior testing

An in‑lab full‑night PAP titration (titration study) is medically necessary when prior testing or clinical context suggests the following disorders or situations:

Central sleep apnea indications: Central sleep apnea, central sleep apnea with Cheyne‑Stokes breathing, or treatment‑emergent central sleep apnea identified on prior HSAT or prior PSG.

Complicated parasomnias or seizure concern: Complicated parasomnias that are potentially injurious or when there is stated concern for nocturnal seizure activity; a complete description, assessment, and discussion of signs/symptoms must be included in the record.

inv-04: HSAT - Initial testing (adults)

HSAT is medically necessary for initial evaluation of suspected obstructive sleep apnea in adults when ALL of the following are met:

HSAT necessity: Clinical evaluation leads to concern for obstructive sleep apnea (OSA) in adults and the individual is appropriate for unattended HSAT per general guidelines.

inv-05: In-lab PSG - when required

In‑laboratory polysomnography (PSG) is medically necessary when clinical evaluation raises concern for sleep‑disordered breathing AND ONE of the following applies:

Questionnaire/inability to use HSAT: Validated questionnaire (e.g., STOP‑BANG or Berlin) or history/physical permitting completion indicating need for in‑lab testing; OR inability to safely use HSAT due to mobility/dexterity/cognitive limitations.

Failed or technically inadequate HSAT: HSAT was attempted and is negative or technically inadequate (report required); technically inadequate HSAT recordings lack a minimum of 4 hours of oximetry and flow data.

Specific comorbidities or physiologic thresholds: Presence of comorbid diagnoses or clinical scenarios (e.g., obesity with BMI ≥45 or BMI ≥30 plus elevated PCO2 or serum bicarbonate ≥27) that meet policy thresholds prompting in‑lab testing.

inv-06: In-lab polysomnography (diagnostic and titration) medical necessity

PSG (in‑lab full night diagnostic, split‑night, or full‑night PAP titration) is medically necessary when clinical evaluation raises concern for sleep‑disordered breathing AND one of the specific condition sets below is met.

Prior HSAT/HSAT failure or safety concerns: Any one of: validated questionnaire or equivalent H&P indicating need for in‑lab testing; inability to use HSAT safely; attempted HSAT negative or technically inadequate (report required; inadequate HSAT lacks minimum 4 hours of oximetry and flow data).

Obesity‑related indications: Any one of: BMI ≥45; BMI ≥30 plus awake ABG/EtPCO2/TcPCO2 PCO2 ≥45 or VBG PCO2 ≥50 mmHg; BMI ≥30 plus serum bicarbonate ≥27 with concern for OHS.

Pulmonary disease: Moderate to severe pulmonary disease demonstrated by nocturnal oxygen use; ABG PO2 <60 or PCO2 ≥45; or PFTs with FEV1 ≤69% predicted.

Neurological disease: Documented neurological disease that precludes HSAT use or raises concern for central sleep apnea/hypoventilation (e.g., neuromuscular disease such as ALS).

Cardiac indications: Moderate to severe CHF with pulmonary congestion or LVEF <45%; pulmonary hypertension (mPAP >20 mmHg) or echocardiographic evidence as specified.

Other critical illness documented in the record that would prevent HSAT use.

Chronic severe insomnia: Documented chronic severe insomnia by validated questionnaire (ISI ≥22).

Chronic daily opioid use: Daily long‑acting opioid use or daily opioid use with stated concern for central sleep apnea.

Titration (bi‑level) indications: Bilevel PAP specifically requested (E0470/E0471) when CPAP/APAP tried and ineffective/intolerable; or diagnoses like central sleep apnea, treatment‑emergent central sleep apnea, neuromuscular/restrictive thoracic disease, severe COPD with awake PaCO2 ≥52 mmHg, OHS, or other defined hypoventilation syndromes.

Sleep‑related hypoxemia: Sustained oxygen desaturation ≤88% for ≥5 total minutes independent of respiratory events on prior study; in obesity, OHS confirmation required per defined criteria.

Documented OSA with unsuccessful APAP: APAP trial ≥30 days with machine download showing AHI ≥5/hr and ongoing symptoms, or APAP use ≥4 hours/night on 70% nights with continued symptoms, or APAP intolerance despite interventions; qualifies for in‑lab full‑night PAP titration.

Other specified scenarios: Complicated parasomnias (potentially injurious or seizure concern) requiring PSG; REM behavior disorder or suspected PLMD with functional impairment when not attributable to other disorders.

inv-07: Other sleep disorder indications for PSG

In‑lab PSG (full night, split‑night, or titration) is medically necessary for certain non‑apnea sleep disorders when safety concerns, injury risk, seizure suspicion, or diagnostic complexity exist.

Complicated parasomnias that are potentially injurious or when there is concern for nocturnal seizures; documentation must include complete description, assessment, and discussion of signs/symptoms.

REM Behavior Disorder and PLMD: REM Behavior Disorder requiring clear description of dream‑enacting behaviors with vocalization and complex motor behaviors; suspected Periodic Limb Movement Disorder with insomnia or impaired daytime function when not attributable to another disorder. Restless Leg Syndrome does not require PSG.

inv-08: Split night study

A split‑night PSG (diagnostic portion followed by PAP titration on the same night) is medically necessary when BOTH of the following are met:

Split‑night study requirements: 1) Diagnostic AHI ≥15 events/hour during at least 2 hours of recording time on the diagnostic PSG; AND 2) At least 3 hours are available for PAP titration during the same night.

inv-09: Titration study after attempted split night

If split‑night criteria are not met or the split‑night cannot be completed, the decision between a second‑night in‑lab full‑night PAP titration versus immediate home APAP (E0601) is determined by general guidelines and clinical judgment.

Second‑night titration vs home APAP: When split‑night cannot be completed and the diagnostic night met criteria for a sleep‑related breathing disorder, necessity of a second‑night in‑lab full‑night PAP titration versus immediate APAP (E0601) is determined by General Guidelines (SL‑1.0) considering prior APAP trial, comorbidities, and patient factors.

inv-10: Split-Night Study (In-lab)

Split‑night PSG (in‑lab PSG plus PAP trial) is medically necessary when BOTH of the following are satisfied:

Split‑Night PSG criteria (both required): 1) Apnea‑Hypopnea Index (AHI) ≥15/hour during at least 2 hours of diagnostic recording; AND 2) ≥3 hours available for PAP titration during the same night.

inv-11: PSG followed by MSLT — Medical Necessity

PSG immediately followed by MSLT is medically necessary for suspected narcolepsy or idiopathic hypersomnia when ALL of the following are met:

Symptom duration: Recurrent daytime naps or lapses into sleep daily for at least 3 months.

Associated features: Additional features may include cataplexy, sleep paralysis, hypnagogic/hypnopompic hallucinations, automatic behaviors, or disrupted major sleep episode.

Exclude alternative causes: Excessive sleepiness is not better explained by OSA or other SDB, circadian disorder, insomnia, inadequate sleep, PLMD, medication/substance use, mental or medical disorder.

Sufficient prior sleep: Sufficient sleep must be documented for the prior 3 months per age‑based thresholds (adults ≥7 hrs/24 hr, teens/adolescents per age guidance).

PSG precedes MSLT: MSLT must immediately follow a diagnostic PSG; MSLT cannot follow a split‑night or PAP titration study where pressures were adjusted.

inv-12: Repeat PSG + MSLT

Repeat PSG followed by MSLT is medically necessary when EITHER of the following applies:

Repeat MSLT — prior non‑confirmatory test: Previous PSG/MSLT did not confirm the suspected diagnosis (narcolepsy or idiopathic hypersomnia).

Change in symptoms: Change in clinical symptoms that might alter a previous diagnosis of narcolepsy or idiopathic hypersomnia.

inv-13: Maintenance of Wakefulness Testing (MWT)

Maintenance of Wakefulness Test (MWT) using the 40‑minute protocol is medically necessary when ALL of the following are met:

Diagnosed disorder and stability: Individual has a diagnosed sleep disorder associated with excessive daytime sleepiness and is clinically stable on effective treatment with documented adherence.

Treatment efficacy and adherence for PAP: If on PAP, device download shows AHI <5/hr AND device use ≥4 hours/night on 70% of nights during a consecutive 30‑day period AND therapy has resolved snoring/increased upper airway resistance.

Purpose for MWT: There is a stated need to objectively document ability to maintain wakefulness due to unreliable history or a personal/public safety concern.

inv-14: Repeat Diagnostic Study — Medical Necessity

Repeat diagnostic testing (HSAT or in‑lab PSG) is medically necessary when ANY of the following apply:

Inadequate prior test: Previous medically necessary sleep test results were inadequate/non‑diagnostic (report required), e.g., limited sleep time or technically inadequate HSAT (<4 hours oximetry/flow), or rescored HSAT with 3% hypopneas showing AHI <5/hr.

Significant weight change or management change: Weight change ≥10% with desire to change therapy or other management change (weight loss or gain), or post‑bariatric surgery >3 months with >10% weight loss when retesting would change management.

Post‑surgical reassessment: Reassessment after upper airway surgery post‑healing when concern for relapse or to evaluate need for continued therapy.

Oral appliance or other therapy change: OSA treated with an oral appliance when there is new/replacement OA, symptoms despite adequate use, ≥10% weight change, or following OA adjustments.

Unavailable prior results: Prior medically necessary test results are unavailable and the provider documents a reasonable effort to obtain the prior report.

inv-15: Repeat Titration — Medical Necessity

Repeat PAP titration is medically necessary when ANY of the following criteria are met:

Clinical change prompting retitration: Significant clinical change such as weight change ≥10% with return/intolerance, recurrent or persistent symptoms despite prior response, development/worsening hypertension despite ≥3 months of adherent PAP, new decompensated heart failure, new stroke/TIA, or newly discovered arrhythmia/bradycardia (especially if during sleep). Prior adherence must be demonstrated when applicable (PAP ≥4 hours/night on 70% nights).

PAP machine download abnormal: PAP device download demonstrates elevated AHI with return of symptoms indicating inadequate therapy on current settings.

Inadequate prior titration: Previous PAP titration was inadequate/non‑diagnostic (report required) or prior medically necessary test report unavailable despite documented effort.

Device change requiring bilevel titration: CPAP/APAP ineffective or not tolerated and bi‑level PAP titration (HCPCS E0470 or E0471) is requested based on clinical indications.

inv-16: Repeat titration - general

Repeat PAP titration is generally not medically necessary unless specific criteria are met.

Repeat titration — general triggers: Repeat titration is medically necessary when there is a significant change in clinical status that may alter SDB type/severity or recurrent/continued symptoms despite adherence; repeat titration solely to supply new PAP equipment or to assess PAP efficacy without significant clinical change is not medically necessary.

inv-17: Repeat titration - CPAP

For individuals currently on CPAP who meet adherence criteria (≥4 hours/night on 70% of nights during a consecutive 30‑day period within the past year), in‑lab full‑night titration or unattended APAP is medically necessary when ANY of the following occur:

Triggers for CPAP‑treated individuals: Weight increase ≥10% with return of symptoms; weight decrease ≥10% with intolerance of PAP pressure; insufficient clinical response with ongoing symptoms; recurrence of symptoms after initial response; development/worsening hypertension despite ≥3 months adherent PAP; new decompensated heart failure or stroke/TIA; newly discovered arrhythmia or bradycardia particularly during sleep; PAP download shows elevated AHI with return of symptoms; prior titration inadequate; or prior medically necessary test unavailable despite documented effort.

inv-18: Repeat titration - Bilevel/APAP/ASV

For individuals currently on bilevel PAP, APAP, or ASV who meet adherence criteria (≥4 hours/night on 70% of nights during a consecutive 30‑day period within the past year), in‑lab full‑night titration is medically necessary when ANY of the following occur:

Triggers for bilevel/APAP/ASV‑treated individuals: Same triggers as for CPAP: ≥10% weight change with symptom changes, insufficient clinical response, symptom recurrence, new/worsening hypertension despite ≥3 months adherent PAP, new decompensated heart failure or stroke/TIA, newly discovered arrhythmia/bradycardia during sleep, PAP download shows elevated AHI with return of symptoms, prior titration inadequate, or prior test unavailable despite documented effort.

inv-19: HGNS pre-implantation

Hypoglossal nerve stimulation (HGNS) pre‑implantation diagnostic testing — in‑lab PSG is medically necessary under the following pre‑implant conditions:

HGNS pre‑implant criteria: ALL of the following: evaluation performed by or in consultation with a board‑eligible/certified sleep physician; BMI ≤40; AHI or REI ≤100; continued PAP intolerance after a minimum three‑month trial (trial may include mask fittings, different masks, pressure changes, desensitization); AND either no prior in‑lab full‑night diagnostic PSG (diagnosis based on HSAT) or prior in‑lab PSG performed >24 months ago or prior PSG ≤24 months ago with clinically significant change in weight/symptoms as documented.

inv-20: HGNS post-implantation

HGNS post‑implantation testing — in‑lab PSG is medically necessary for device tuning and follow‑up as specified:

Initial post‑implant HGNS PSG: In‑lab full‑night diagnostic sleep study is medically necessary at least 2 months post‑implantation to fine‑tune device parameters and determine therapeutic stimulation settings.

Repeat post‑implant HGNS PSG: Repeat in‑lab PSG is medically necessary if clinical response is insufficient despite regular treatment, weight increases ≥10% with return of symptoms, or prior medically necessary study was inadequate (report required).

inv-21: TPNS pre/post-implantation

Transvenous phrenic nerve stimulation (TPNS/Remede®) pre‑ and post‑implantation PSG requirements:

TPNS pre‑implant (prior PSG >12 months or HSAT anytime): ALL of: age ≥18; prior study showing moderate‑to‑severe central sleep apnea (central AHI ≥15/hr); CSA not primarily due to opioids; absence of transient conditions that could increase CSA severity (e.g., stroke/TIA within 6 months; new HF <6 months; LV systolic dysfunction EF ≤40% not on optimal therapy); PAP contraindicated/failed/intolerant after ≥3‑month trial; supplemental oxygen contraindicated/ineffective/intolerated; evaluation by or in consultation with a board‑eligible/certified sleep physician.

TPNS repeat PSG (prior PSG within 12 months): ALL of: clinically significant changes in weight/symptoms/medications/neurologic or cardiovascular status; age ≥18; prior moderate‑to‑severe CSA (central AHI ≥15/hr); CSA not primarily due to opioids; absence of transient causes; PAP contraindication/failure/intolerance after 3‑month trial; supplemental oxygen contraindicated/ineffective/intolerated; evaluation by board‑eligible/certified sleep physician or in consultation.

TPNS post‑implant initial PSG: In‑lab full‑night diagnostic PSG with interrogation/programming of the phrenic nerve stimulator can be performed at least 2 months after implantation to fine‑tune device parameters and determine therapeutic/tolerable settings.

inv-22: Repeat PSG for prior CSA (TPNS consideration)

Repeat in‑lab PSG for prior central sleep apnea (TPNS consideration) is medically necessary when ALL of the following are met:

Repeat PSG for prior CSA criteria: There have been changes in weight, symptoms, medications, neurological or cardiovascular status suggesting clinically significant change; age ≥18; prior study showed moderate‑to‑severe CSA (central AHI ≥15/hr); CSA not primarily attributed to opioids; absence of transient‑cause medical conditions (e.g., stroke/TIA within 6 months, new HF <6 months, LV dysfunction EF ≤40% not on optimal therapy unless contraindicated); PAP contraindication, failure or intolerance after a 3‑month trial; supplemental oxygen contraindicated/ineffective/not tolerated; evaluation for TPNS by or with a board‑eligible/certified sleep physician.

inv-23: Post-implantation PSG (TPNS)

Post‑implantation PSG for TPNS — timing and repeat testing:

Initial post‑implant TPNS PSG: In‑lab full‑night PSG with interrogation/programming of the phrenic nerve stimulator system can be performed at least 2 months after implantation for device parameter fine‑tuning and to determine therapeutic/tolerable settings.

Subsequent post‑implant retesting: Retesting may be performed if clinical response is insufficient despite compliant use OR if prior medically necessary sleep test results were inadequate due to limited sleep time or other variables (report required).

inv-24: Pre-treatment sleep testing (no prior test)

Pre‑treatment sleep testing (no prior test) for adults: HSAT or PSG is medically necessary when ALL of the following are met:

Pre‑treatment testing — adult OSA evaluation: Age ≥18; BMI ≥30; AND one or more signs/symptoms consistent with OSA (unexplained excessive daytime sleepiness/fatigue impairing quality of life; snoring/snorting/choking/gasping; witnessed apneas; awakening with breath‑holding/shortness of breath/gasping/coughing/choking; resistant or refractory hypertension; observed oxygen desaturations during sleep or sedation; presence of atrial fibrillation; presence of systolic congestive heart failure; new/recent stroke or TIA within 6 months). Either HSAT or PSG selected per general HSAT vs in‑lab guidance.

inv-25: Repeat testing after prior AHI ≥15

Repeat HSAT or PSG is medically necessary when ALL of the following are met for individuals with prior AHI ≥15:

Repeat testing after prior AHI ≥15: Age ≥18; BMI ≥30; AND at least one of: ≥10% weight loss; changes in symptoms, medications, neurological status, or cardiovascular status suggesting clinically significant change in sleep study results.

inv-26: Repeat PSG after prior AHI <15

A repeat PSG is medically necessary when ALL of the following are met for individuals with prior AHI <15:

Repeat PSG after prior AHI <15: Age ≥18; BMI ≥30; prior study report showing AHI <15 (report required) AND at least one of: ≥10% weight gain since the study; changes in symptoms, medications, neurological status, or cardiovascular status suggesting clinically significant change in sleep study results.

inv-27: Repeat PSG for central-dominant prior study

A repeat PSG is medically necessary when ALL of the following are met for individuals whose prior study showed central‑dominant events:

Repeat PSG for central‑dominant prior study: Age ≥18; BMI ≥30; prior report showing central apneas plus central hypopneas comprising ≥50% of total apneas/hypopneas OR Cheyne‑Stokes breathing; AND changes in symptoms, medications, neurological or cardiovascular status suggesting clinically significant change in sleep study results (report required).

inv-28: HSAT-to-PSG conversion

Conversion from prior HSAT to in‑lab PSG is medically necessary when ALL of the following are met:

HSAT‑to‑PSG conversion: Age ≥18; BMI ≥30; prior HSAT report (required) showing at least one of: AHI <15; central apneas plus central hypopneas ≥50% of total events; or Cheyne‑Stokes breathing — HSAT limitations for central apnea detection justify conversion to in‑lab PSG.

inv-29: PAP initiation coverage

PAP initiation (device and supplies) is covered when diagnostic testing and ordering requirements are met:

PAP ordering and diagnosis: Order for PAP and supplies placed by an eligible treating medical provider AND valid sleep testing demonstrates a positive diagnosis of a sleep‑related breathing disorder per policy definitions (OSA: AHI/RDI/REI ≥15, or ≥5 and <15 with qualifying symptoms/comorbidities).

inv-30: ASV in HFrEF

Adaptive Servo Ventilation (ASV) in heart failure with reduced ejection fraction (HFrEF): ordering conditions

ASV in HFrEF: ASV may be ordered for individuals with HFrEF only if: the treating provider and patient have discussed benefits and risks; the treating provider is a board‑certified sleep medicine physician or is overseen by one; AND there is a plan for follow‑up while on ASV treatment.

inv-31: Initiation of E0601 APAP/CPAP

Initiation of HCPCS E0601 (APAP/CPAP) is covered when ALL of the following are met:

E0601 initiation: 1) Positive diagnosis of OSA or central sleep apnea per HSAT or PSG definitions; AND 2) Device ordered by the treating provider following a clinical evaluation (face‑to‑face or telehealth) where PAP treatment was discussed.

inv-32: Repeat APAP assessment (E0601)

Repeat APAP assessment (E0601) for individuals on fixed CPAP is covered when ALL of the following are met:

Repeat APAP assessment: 1) Positive diagnosis of OSA by HSAT or PSG; 2) Attempted compliance with fixed CPAP (≥4 hours/night on 70% of nights) has not adequately treated signs/symptoms; 3) Persistent symptoms or unimproved AHI/RDI despite instruction, mask refitting/adjustment, and education from treating physician or supplier.

inv-33: Initiation and establishing compliance for E0601

Establishing compliance for initial E0601 (APAP/CPAP) — covered when ALL of the following are met:

Establish compliance for E0601: 1) Positive diagnosis of OSA or central sleep apnea; 2) Device ordered after clinical evaluation discussing PAP; 3) Device used ≥4 hours/night on 70% of nights during a consecutive 30‑day period anytime during the first 3 months; 4) Clinical reevaluation within the first 3 months to evaluate symptoms.

inv-34: Repeat initiation and compliance extension (E0601)

Repeat initiation or extension to establish compliance for E0601 is covered when ALL required conditions are met:

Repeat initiation after failure: A documented clinical evaluation occurred to determine etiology of failure to respond to PAP and a support plan to address causes is documented.

Extension of establishing compliance: 1) History of failure to resolve symptoms or unimproved AHI during initial compliance period OR inconsistent usage related to fit/education/intolerance/device malfunction; AND 2) Individual has received instruction, mask refitting/adjustment, and education within the past 30 days from the ordering physician or supplier.

inv-35: Replacement APAP/CPAP (E0601)

Replacement APAP/CPAP (E0601) is covered when ALL of the following are met:

Replacement E0601: Continued resolution of symptoms and improved AHI on therapy; device had been consistently used ≥4 hours/night on 70% of nights; device is not operating; DME supplier has physically evaluated device and determined it cannot be repaired; and device is no longer under warranty.

inv-36: Initiation of HCPCS E0470 (bilevel spontaneous)

Initiation of HCPCS E0470 (bilevel, spontaneous) is covered when ALL of the following are met (ONE of the listed medical conditions must be documented):

E0470 initiation conditions: Documented condition such as: OSA where diagnosis per General Guidelines AND CPAP/APAP have been tried and proven ineffective or not tolerated; neuromuscular disease or severe thoracic cage abnormality with specified physiologic thresholds (e.g., VC <80% with symptoms, ABG PaCO2 ≥45, EtCO2/TcPCO2/VBG thresholds, sustained nocturnal desaturation criteria, VC ≤50% predicted, MIP ≤60 cm H2O, SNIP ≤40 cm H2O); severe COPD with awake PaCO2 ≥52 mmHg and OSA/CPAP considered and ruled out; OHS per defined criteria; or other hypoventilation syndromes meeting CO2 thresholds.

inv-37: Continued E0470 therapy

Continued E0470 therapy after the initial 3‑month period requires BOTH of the following when the indication is OSA, CSA, or treatment‑emergent CSA:

E0470 continuation: 1) PAP device used ≥4 hours/night on 70% of nights during a consecutive 30‑day period anytime during the first 3 months; AND 2) Clinical reevaluation in the first 3 months to evaluate symptoms.

inv-38: Replacement bilevel device

Replacement bilevel device (E0470) is covered when ALL of the following are met:

Replacement E0470: For OSA/CSA/TECSA: continued resolution of symptoms and improved AHI/RDI on therapy; device had been consistently used ≥4 hours/night on 70% of nights; device is not operating; DME supplier physically evaluated device and determined it cannot be repaired; device is no longer under warranty. For other indications, documentation of continued benefit and DME evaluation as above is required.

inv-39: Initiation of HCPCS E0471 (bilevel ST)

Initiation of HCPCS E0471 (bilevel S/T or ASV) is covered when ALL of the following are met (ONE of the documented medical conditions must apply):

E0471 initiation: Documented condition such as: central sleep apnea (primary or with Cheyne‑Stokes) meeting valid testing criteria; treatment‑emergent central sleep apnea; neuromuscular/restrictive thoracic disorder with physiologic thresholds; severe COPD with awake PaCO2 ≥52 mmHg; OSA where CPAP considered/ruled out; OHS per defined criteria; other hypoventilation syndromes; or sleep‑related hypoventilation per General Guidelines.

inv-40: Continued E0471 therapy

Continued E0471 therapy after the initial 3‑month period requires BOTH of the following when the indication is OSA, CSA, or treatment‑emergent CSA:

E0471 continuation: 1) PAP device used ≥4 hours/night on 70% of nights during a consecutive 30‑day period anytime during the first 3 months; AND 2) Clinical reevaluation in the first 3 months to evaluate symptoms.

inv-41: ASV initiation

ASV initiation (HCPCS E0471) — covered when ONE of the following documented medical conditions is present:

ASV indications: Central sleep apnea (primary or with Cheyne‑Stokes), treatment‑emergent central sleep apnea, central sleep apnea due to opioids, or specified hypoventilation syndromes as defined. For individuals with HFrEF, additional requirements apply: provider/patient discussion of benefits/risks, treating provider is board‑certified sleep physician or overseen by one, AND a follow‑up plan while on ASV.

inv-42: Obesity hypoventilation syndrome (OHS)

Obesity hypoventilation syndrome (OHS) coverage for PAP initiation — covered when ALL of the following are met:

OHS criteria: BMI ≥30 kg/m2 PLUS either awake ABG/EtPCO2/TcPCO2 with PCO2 ≥45 mmHg OR venous blood gas PCO2 ≥50 mmHg; additional qualifiers such as recent hospitalization with persistent awake hypoventilation, non‑severe OSA, or severe OSA with ongoing hypoventilation despite 3 months of compliant CPAP/APAP or bilevel use may apply per policy.

inv-43: Continued therapy (first 3 months)

Continued therapy for PAP/ASV after the initial 3 months — coverage requires ALL of the following:

Continued PAP usage: Device used ≥4 hours per night on 70% of nights during a consecutive 30‑day period anytime during the first 3 months, AND clinical reevaluation in the first 3 months to evaluate symptoms.

inv-44: Replacement device

Replacement device coverage (PAP or ASV) — covered when ALL of the following are met:

Replacement device criteria: Continued resolution of symptoms and improved AHI on therapy; device had been consistently used ≥4 hours/night on 70% of nights; device is not operating; DME supplier physically evaluated device and determined it cannot be repaired; device is no longer under warranty.

inv-45: Humidifier coverage

Heated (E0562) and non‑heated (E0561) humidifiers coverage conditions:

Initial humidifier: Requested by treating physician and an approved PAP device (E0470/E0471 or E0601) has been authorized; no previous humidifier has been provided.

Replacement humidifier: Continued resolution of symptoms and improved AHI on therapy; device had been consistently used ≥4 hours/night on 70% of nights; device is not operating; DME supplier evaluated device and determined it cannot be repaired; device no longer under warranty.

inv-46: Loaner rental

Loaner rental (up to 30 days) coverage conditions:

Loaner rental: CPAP/APAP/BPAP loaner rental up to 30 days is medically necessary when there is documentation of device malfunction and evidence that equipment has been sent for repair/assessment.

inv-47: Mask/supply coverage

PAP masks and parts are covered when the following conditions are met:

Mask/supply coverage: Requested mask/part is within allowable frequency limits and provided data meets compliance criteria (device used ≥4 hours/night on 70% of nights) with 30 continuous days of compliance data provided from within 6 months prior to the request; compatibility and 'no other mask ordered' rules per HCPCS code must be followed.

inv-48: Physician PAP service (94660)

Physician PAP service (CPT 94660) coverage conditions:

CPT 94660 requirements: Face‑to‑face physician service for application or adjustment of mask or pressure titration or PAP‑related service; service cannot be adequately provided by appropriate respiratory therapist/licensed clinician/sleep technologist within scope of practice; AND another E/M service is not performed.

inv-49: Positive airway pressure - accessories and supplies (SL-4.3)

PAP accessories and supplies (SL‑4.3) are covered when ALL of the following are met:

PAP supply requirements: Requested accessory or supply meets specified frequency and compatibility rules for the HCPCS code AND provided compliance data demonstrates device use ≥4 hours/night on 70% of nights with 30 continuous days of compliance data within 6 months prior to the request.

inv-50: Custom-fit oral appliances (SL-9.1)

Custom‑fit oral appliances are medically necessary when ALL of the following criteria are met:

Oral appliance diagnosis: Positive diagnosis of OSA on a covered sleep study as demonstrated by either AHI/RDI/REI ≥5 and <15 with documented symptoms/comorbidity OR AHI/RDI/REI ≥15.

PAP trial/contraindication/preference: Documentation of one of: intolerance or lack of benefit after a minimum 1‑month trial of PAP; PAP contraindicated as documented by treating physician; OR patient preference for oral appliance after discussion AND AHI/RDI/REI <30.

Ordering and provider: Device ordered by treating medical provider following a face‑to‑face visit and provided/followed by a qualified licensed dentist (DDS or DMD) for fitting and follow‑up.

inv-51: Replacement custom fit oral appliances (SL-9.1.3)

Replacement custom‑fit oral appliances can be replaced when ALL of the following are met:

Replacement oral appliance: Device is being used consistently with continued symptom resolution; ordered by treating medical provider after face‑to‑face visit; qualified licensed dentist provides replacement and follow‑up; AND one of: device lost/stolen/irreparably damaged due to accident/natural disaster/breakdown from regular use OR device is >5 years old.

inv-52: Pediatric sleep study limitations

Pediatric limitations regarding home/portable sleep studies:

Pediatric HSAT limitation: Use of home/portable sleep studies for diagnosis of OSA in children (≤17 years) is considered experimental, investigational, or unproven and is not sufficient to exclude OSA or reliably assess severity due to lack of CO2 and arousal monitoring.

inv-53: Initial Polysomnography for Diagnosis

Initial in‑lab full‑night diagnostic PSG is appropriate for children (≤17 years) when evaluating suspected sleep‑related breathing disorders and specified findings are present.

Initial pediatric PSG indications: In‑lab full‑night diagnostic PSG for children is indicated when symptoms suggestive of sleep‑related breathing disorder are present (e.g., snoring, witnessed apnea, labored breathing, disturbed sleep, behavioral or learning problems, unexplained enuresis, daytime sleepiness, cor pulmonale, polycythemia) OR when one of specified supporting findings (failure to thrive, tonsillar hypertrophy with symptoms, adenoidal facies, obesity, craniofacial or neurologic abnormalities) is documented and the provider is concerned the finding is related to OSA.

inv-54: Initial Polysomnography for PAP Titration

Pediatric in‑lab full‑night PAP titration:

Initial pediatric PAP titration: In‑lab full‑night PAP titration is medically necessary in children with an established diagnosis of pediatric obstructive sleep apnea as defined in policy.

inv-55: Repeat Polysomnography for Diagnosis

Repeat pediatric in‑lab PSG for diagnosis is medically necessary in the following circumstances:

Repeat pediatric diagnostic PSG: Significant weight change after obesity‑related OSA to reassess need for continued therapy; ongoing symptoms despite non‑PAP therapy; initial PSG inadequate/non‑diagnostic and caregiver reports it was unrepresentative; residual OSA post‑adenotonsillectomy when preop mild OSA with residual symptoms or preop moderate‑severe OSA or obesity/craniofacial/neurologic disorders are present.

inv-56: Repeat PAP Titration

Repeat pediatric PAP titration is medically necessary when clinically indicated:

Repeat pediatric PAP titration: Periodic reevaluation to adjust CPAP settings based on the child's growth pattern or presence of recurrent symptoms while on PAP.

inv-57: Special Scenarios

Special pediatric scenarios in which in‑lab PSG or PAP titration is medically necessary include:

Pediatric special scenarios: Screening PSG for children with Down syndrome even without symptoms; congenital central alveolar hypoventilation or sleep‑related hypoventilation due to neuromuscular/chest wall disorders; atypical/frequent/potentially injurious parasomnias; differentiating parasomnia from nocturnal epilepsy when prior evaluations inconclusive; PSG prior to decannulation for tracheostomy; periodic PSG to adjust ventilator settings; suspected nocturnal seizures; suspected PLMD when other disorders are excluded; and select inpatient or discharge evaluations for hypoventilation.

inv-58: CPAP in Pediatrics

Pediatric CPAP initiation criteria:

Pediatric CPAP indications: CPAP is medically necessary when ALL of the following are met: PSG‑established OSA; AND adenotonsillectomy has been unsuccessful or is clinically inappropriate, or definitive surgery must await dental/facial development.

Sleep testing is not medically necessary for isolated insomnia when there are no additional symptoms suggesting another sleep-fragmenting disorder (for example obstructive sleep apnea or periodic limb movement disorder). Pre-operative HSAT screening of asymptomatic bariatric surgery candidates is likewise not medically necessary. A clear description of relevant sleep-related signs and symptoms (e.g., unexplained excessive daytime sleepiness or fatigue, snoring/snorting/choking/gasping, or witnessed apneas) must be documented before diagnostic sleep testing will be considered.

In-laboratory polysomnography (PSG) is not required for routine, uncomplicated disorders of arousal (such as sleep terrors, confusional arousals, or sleepwalking) or for typical parasomnias unless there is a specific safety concern or suspicion of nocturnal seizures. PSG (full night, split night, or in-lab titration) is medically necessary when these arousal-type disorders are complicated (potentially injurious) or when clinical features raise concern for seizures, and the record must include a complete description and assessment of signs and symptoms.

The presence of a CPT/HCPCS code in the policy tables is informational only and does not imply that the code is managed by prior authorization or guarantees payment. Providers should verify plan-specific prior authorization and payment rules in the applicable health plan documents.

Polysomnography is not medically necessary for typical, uncomplicated disorders of arousal (e.g., sleep terrors, confusional arousals, sleepwalking) or for routine evaluation of uncomplicated parasomnias in the absence of safety issues or seizure concern. When parasomnias are potentially injurious or nocturnal seizure activity is suspected, an in‑lab PSG may be appropriate if the clinical documentation supports that concern.

Repeat diagnostic or titration testing is not medically necessary solely to obtain replacement PAP equipment or to provide new supplies or devices unless there is a documented and clinically significant change in status that would alter diagnosis or management (examples include ≥10% weight change, new or recurrent symptoms despite adherence, or inadequate prior testing with prior report submitted).

Repeat in‑lab PAP titration is generally not medically necessary for asymptomatic individuals on PAP therapy or when the only purpose is to supply new equipment. Repeat titration may be considered when there is a significant clinical change (e.g., weight change ≥10%, return of symptoms despite documented adherence) per the policy criteria.

Transvenous phrenic nerve stimulation (TPNS) candidacy and related PSG criteria exclude central sleep apnea that is primarily attributable to opioid use and exclude patients with recent stroke or TIA; requests for TPNS-related evaluation require documentation that CSA is not opioid‑related and that excluded transient conditions (for example stroke/TIA within 6 months) are absent.

Medication trial exclusions and safety considerations: participants with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN‑2) were excluded from tirzepatide trials and GLP‑1 receptor agonists carry a boxed contraindication in such patients; the policy notes these trial exclusions when addressing related pharmacologic treatment pathways.

Formal sleep testing is not required to document severe COPD indications when those criteria are met and OSA/CPAP have been considered and ruled out; initiation of bilevel PAP for severe COPD is tied to documented physiologic thresholds (for example awake arterial PaCO2 ≥52 mmHg) as specified in the policy.

Replacement devices (including bilevel and ASV) are not supported unless the device is non‑operating, has been evaluated and found unrepairable by the DME supplier, and is no longer under warranty. Requests for replacement must include DME supplier documentation of physical evaluation and repair attempts.

Oral appliances intended to treat temporomandibular joint (TMJ) disorders, tongue‑retaining or tongue‑positioning devices, and devices used only for snoring without an OSA diagnosis are considered experimental, investigational, or unproven and are not covered under the policy.

Polysomnography is not supported for routine evaluation of uncomplicated typical parasomnias or for adenotonsillar hypertrophy alone without other clinical signs of sleep‑disordered breathing; PSG is reserved for complicated parasomnias, safety concerns, or when there is suspicion of nocturnal seizures.

Use of CPT 95807 or 95807‑52 specifically to perform a daytime PAP‑NAP (abbreviated cardiorespiratory study intended to improve PAP adherence) is not covered. A small pilot study showed improved adherence but no controlled studies have been published; therefore PAP‑NAP using these CPT codes will be denied.

Coverage decisions may be further limited by referenced CMS Local Coverage Determinations (for example L33718, L33800, L35050). Providers should follow the applicable LCDs and the member's plan documents when determining coverage and prior authorization requirements.

Routine HSAT or PSG for asymptomatic individuals (for example pre‑operative screening or medication initiation without symptoms) is not medically necessary. Specifically, sleep testing prior to initiation of Zepbound (tirzepatide) in asymptomatic individuals is not required; testing is indicated only when the policy's symptom and diagnostic criteria are met (age ≥18, BMI ≥30, plus one or more OSA signs/symptoms).

Atrial fibrillation alone, without other qualifying comorbidities or symptoms, does not meet criteria for an in‑lab sleep study. The policy requires a comprehensive clinical evaluation and documented qualifying signs/symptoms or comorbidities before PSG is authorized.

The policy recognizes that CPT 95807 or 95807‑52 may be used by some providers to request a PAP‑NAP, but reiterates that use of these codes for PAP‑NAP is considered experimental or unproven in many circumstances and is specifically listed as a not covered procedure in this guideline.

Restless legs syndrome (RLS) is a clinical diagnosis and does not require PSG for confirmation. Typical parasomnias without safety concerns or suspicion for nocturnal seizures do not require PSG; when parasomnias are complex or potentially injurious, in‑lab testing may be appropriate as documented in the record.

Routine follow‑up HSAT or PSG for asymptomatic individuals on PAP or non‑PAP therapy is not medically necessary in the absence of persistent or recurrent symptoms, significant clinical change, or inadequate prior testing. Repeat titration is not supported solely to evaluate efficacy absent recurrent symptoms and confirmed device adherence.

Routine follow‑up HSAT or PSG is not routinely necessary to continue therapy. Repeat titration or routine reassessment without objective or subjective indications (for example documented symptom recurrence, ≥10% weight change, new cardiac/neurologic events, or inadequate prior testing) is not supported.

Post‑treatment sleep testing is not required solely to continue or resume certain pharmacologic treatments (for example Zepbound). Repeat sleep testing for reassessment should follow the policy's repeat testing criteria (weight change, symptom change, prior inadequate test, or planned change in management).

Supply and accessory requests (masks, cushions, tubing, filters, etc.) that lack required compliance data are at risk for denial. The policy requires provision of 30 continuous days of compliance data within the prior 6 months showing device use of ≥4 hours per night on 70% of nights to approve many routine supply requests; absence of these data may result in non‑coverage.

Use of HSAT or other limited home/portable sleep studies to diagnose obstructive sleep apnea in children (≤17 years) is considered experimental, investigational, or unproven. Home/portable studies lack critical monitoring (for example CO2 and arousal monitoring) and therefore are not sufficient to exclude OSA or reliably assess severity in pediatric patients.

Repeat in‑lab PSG for routine follow‑up after adenotonsillectomy when pediatric symptoms have resolved is not supported. Similarly, PSG is not supported for routine evaluation of uncomplicated typical arousal disorders (sleep terrors, sleepwalking) in children absent safety concerns or other indications. The policy also lists several device and therapy options considered experimental, investigational, or unproven (see policy exclusions).

PAP‑NAP is specifically unsupported due to lack of controlled studies demonstrating clinical benefit beyond the pilot data; therefore CPT 95807 and 95807‑52 used for PAP‑NAP are designated as not covered and will be denied when submitted for that purpose.

Provider Actions — Ordering, Documentation, and Authorization

Prior Authorization

Order & interpretation: treating provider orders; sleep‑specialist interpretation

HSAT and PSG orders must come from a treating medical provider and be interpreted by a board‑certified sleep medicine physician (or a provider overseen by one). A current, comprehensive clinical evaluation (face‑to‑face or telehealth) including sleep history, pertinent physical exam elements, relevant prior diagnostic studies, and labs (ABG or serum bicarbonate within one year) is required before a sleep study is considered medically necessary.

Treating medical provider = MD, DO, NP, CNS, or PA for orders.
Interpretation must be by a board‑certified sleep medicine physician or a provider overseen by one.
Clinical evaluation must document sleep symptoms or sufficient history to complete a sleep questionnaire, physical exam, prior studies, and relevant labs.

Prior Authorization

In‑lab PAP titration / bilevel requests require documented CPAP/APAP failure or qualifying diagnosis

In‑lab full‑night PAP titration (billing with HCPCS E0470 or E0471) is medically necessary when CPAP/APAP has been tried and proven ineffective or not tolerated, or when the individual has a qualifying diagnosis (e.g., central sleep apnea, Cheyne‑Stokes, treatment‑emergent CSA, neuromuscular/restrictive thoracic disease, severe COPD, OHS, or other defined hypoventilation).

Request for bilevel titration should document prior CPAP/APAP trial and reason for failure/intolerance or the specific diagnosis listed in the policy.
Document APAP trial details (machine downloads, usage) when applicable (see E0601 criteria).

Note

Codes listed for HSAT/PSG — inclusion ≠ automatic PA or payment

The policy lists the HCPCS and CPT codes used for HSAT and PSG procedures and notes that inclusion of a code in tables does not itself imply prior authorization or guarantee payment; refer to the applicable health plan for management and prior authorization requirements.

Codes are referenced for context; check the member's plan for any prior authorization requirements.

Prior Authorization

PA required for in‑lab titration and related PAP device requests (E0470/E0471/E0601)

Prior authorization is required when requesting in‑lab PAP titration billed with HCPCS E0470 or E0471, or when requesting immediate home APAP (E0601) as the next step after an attempted split‑night; documentation must support the reason for titration or immediate treatment (e.g., prior APAP trial, intolerance, or listed comorbidities).

When billing E0470/E0471 include evidence of prior CPAP/APAP trial or the qualifying physiologic diagnosis/thresholds.
If E0601 (APAP) is used after split‑night failure, document the clinical rationale per guidelines.

Prior Authorization

PA for split‑night, PSG→MSLT sequencing, and repeat titration — meet defined criteria

Prior authorization is required for split‑night studies, MSLT sequencing after PSG, and repeat titration requests; split‑night criteria must be met (diagnostic AHI ≥15/hr during ≥2 hours and ≥3 hours available for titration) and repeat titration requests must meet the policy's change‑in‑status or adequacy criteria.

Split‑night: document diagnostic AHI ≥15/hr over ≥2 hours and ≥3 hours available for titration.
MSLT must follow an adequate PSG and meet the listed clinical criteria.
Repeat titration requires documented significant clinical change or inadequate prior testing; show prior adherence when applicable.

Prior Authorization

PA required for device‑related PSG/titration (HGNS/TPNS) per device criteria

Prior authorization is required for in‑lab diagnostic PSG and PAP titration related to hypoglossal nerve stimulation (HGNS) or transvenous phrenic nerve stimulation (TPNS) pre‑ and post‑implant evaluation when the listed medical necessity criteria are met.

HGNS: pre‑implant criteria include BMI and AHI/REI limits, documented prior PAP intolerance, and evaluation by a sleep physician.
Post‑implantation PSG for device tuning is allowed at ≥2 months post‑implant; repeat testing requires documented inadequate response or other triggers.

Prior Authorization

PA for TPNS‑related PSG requires prior CSA documentation and exclusion of transient causes

Repeat in‑lab PSG for TPNS (Remede®) evaluation or device‑related titration is medically necessary only when the specific TPNS criteria are met (e.g., prior moderate–severe CSA, not opioid‑related, age ≥18, changes suggesting clinically significant change, and prior PAP contraindication/failure after a 3‑month trial); authorization should document these elements.

Provide prior PSG report showing central AHI ≥15/hr and evidence that CSA is not opioid‑attributed.
Document attempts/trials of PAP and reasons for PAP failure/intolerance.

Note

Code listing ≠ automatic prior authorization; verify with health plan

Inclusion of device and supply codes in the policy's tables does not by itself mean those codes require prior authorization; providers must verify prior authorization requirements with the applicable health plan.

Prior authorization of a code is not a guarantee of payment; follow the member's Certificate of Coverage/Evidence of Coverage.

Prior Authorization

PA for E0601 (APAP/CPAP): positive diagnosis, ordering evaluation, and compliance data

Initiation of HCPCS E0601 (APAP/CPAP) requires a positive diagnosis of OSA or CSA and that the device be ordered after a clinical evaluation where PAP treatment was discussed; establishing compliance requires device use ≥4 hours/night on 70% of nights during a consecutive 30‑day period within the first 3 months and clinical reevaluation.

Document positive diagnostic test (HSAT or PSG) and that PAP was discussed in the clinical evaluation.
For authorization of purchase, provide objective compliance data showing ≥4 hrs/night on 70% nights during a consecutive 30‑day period and clinical reevaluation within 3 months.

Prior Authorization

PA for bilevel PAP (E0470/E0471) requires diagnosis and physiologic thresholds or prior CPAP failure

Initiation of bilevel PAP (HCPCS E0470 spontaneous or E0471 ST/ASV) requires documentation of one of the specified medical conditions and applicable physiologic thresholds (e.g., ABG PaCO2, EtPCO2/TcPCO2/VBG values, nocturnal oximetry criteria) or prior CPAP/APAP failure as detailed in the policy.

For COPD or hypoventilation indications include arterial/CO2 measurements (PaCO2 thresholds) or sleep oximetry evidence as specified.
When bilevel is requested because CPAP failed, include documentation of CPAP/APAP trial and reasons for failure/intolerance.

Prior Authorization

ASV (E0471) initiation: diagnosis required; HFrEF needs documented discussion and specialist oversight

Initiation of ASV (HCPCS E0471 when used as ASV) requires documentation of one of the listed conditions (e.g., central sleep apnea, treatment‑emergent CSA, opioid‑related CSA), and for individuals with HFrEF the provider must document a discussion of benefits/risks, board‑certified sleep physician oversight, and a plan for follow‑up.

For opioid‑related CSA include documentation that CPAP was ineffective, opioid therapy cannot be reduced, central events >50% of total, and central apnea index ≥5/hr.
HFrEF: document benefit/risk discussion, sleep specialist involvement, and follow‑up plan.

Billing Rule

Humidifier (E0562/E0561) initial coverage requires prior PAP device approval and no prior humidifier

Initial humidifier setup (heated E0562 or non‑heated E0561) is authorized when requested by the treating physician after approval of an eligible PAP device and when no prior humidifier has been provided.

Include documentation that a PAP device (E0470/E0471 or E0601) has been approved and that no prior humidifier was provided.

Prior Authorization

PA for PAP supplies: 30 days compliance data showing ≥4 hrs/night on 70% of nights and code‑specific rules

Prior authorization for PAP supplies and accessories requires submission of 30 continuous days of device compliance data within the prior 6 months showing use ≥4 hours/night on 70% of nights, and requests must meet code‑specific frequency and compatibility rules.

Provide 30 consecutive days of compliance data from within 6 months prior to the request.
Confirm requested HCPCS supply code frequency limits and that no conflicting masks/tubing are ordered per policy.

Prior Authorization

Oral appliance prior authorization: positive study plus PAP trial/intolerance and dentist involvement

Custom oral appliance (E0486/E0485/K1027) prior authorization requires documentation of a positive diagnostic sleep study meeting AHI/RDI/REI thresholds and evidence of PAP intolerance/contraindication or a one‑month PAP trial (unless contraindicated) as specified; the device must be ordered after a face‑to‑face visit and provided/followed by a qualified dentist.

Document positive sleep study (AHI/RDI/REI ≥5 with symptoms or ≥15) and PAP trial/intolerance or patient preference when AHI <30.
Include face‑to‑face visit documentation and qualified licensed dentist involvement for fabrication and follow‑up.

Prior Authorization

PA for pediatric PSG/PAP titration: document pediatric symptoms/findings and reasons for split‑night

For pediatric in‑lab full‑night diagnostic PSG or PAP titration (≤17 years), prior authorization should document the pediatric symptoms/findings supporting medical necessity (e.g., snoring, witnessed apnea, tonsillar hypertrophy, failure to thrive) and, for split‑night in children, the reason for split‑night testing.

Provide age and symptom documentation tied to pediatric indications listed in the policy.
When split‑night used in pediatrics, document the clinical rationale.

Documentation Required

Submit prior study results or document reasonable effort to obtain them before requesting additional studies

Providers must submit results of prior sleep studies when requesting authorization for additional studies; if prior study reports are unavailable, the request must document a reasonable effort to obtain them (contacting prior facility/provider, DME supplier, or asking the patient).

Attach prior PSG/HSAT reports when criteria reference prior AHI/central events or when prior study adequacy is in question.
If prior reports are unavailable, document attempts to obtain them to avoid denial.

Note

Follow cited CMS LCDs for device and study authorization requirements

Follow referenced CMS Local Coverage Determinations (L33718, L33800, L35050) as they may contain additional prior authorization or local coverage requirements influencing device or study authorization.

Verify plan/local LCD requirements in addition to this policy when requesting device or study authorization.

Note

Reference sections do not change prior authorization code requirements

The policy includes citations only in parts that do not modify prior authorization lists; those reference pages do not themselves specify PA codes or requirements—providers must rely on their health plan for exact PA code lists.

Reference sections are bibliographic; they do not alter health plan PA rules.

Prior Authorization

PSG required vs HSAT when clinical concerns/comorbidities present

PSG (in‑lab full night, split‑night, or full‑night PAP titration) is required instead of HSAT when the clinical evaluation indicates concern for sleep‑disordered breathing and one or more specified high‑risk conditions or comorbidities are present (see policy list).

Examples include inability to use HSAT safely, technically inadequate HSAT, OHS, severe COPD, neuromuscular disease, moderate‑severe CHF, pulmonary hypertension, chronic severe insomnia, or chronic opioid use as detailed in the policy.

Step Therapy

APAP trial (≥30 days) with objective data expected before in‑lab titration when applicable

A trial of APAP (E0601) of at least 30 days with objective device data (machine downloads demonstrating AHI or usage) is expected prior to in‑lab titration for documented OSA in many cases unless other listed indications (e.g., OHS, central apnea, severe COPD) make in‑lab titration necessary.

Document APAP machine downloads showing AHI ≥5/hr with symptoms, or APAP use ≥4 hrs/night on 70% nights with persistent symptoms, or reasons APAP was intolerable despite interventions.

Step Therapy

HSAT first‑line for adult OSA; escalate to PSG per listed indications

HSAT is first‑line for adult OSA when clinical evaluation supports testing; escalate to in‑lab PSG when the evaluation indicates SDB and any of the policy's in‑lab indications or comorbidities are present.

Use HSAT for typical adult OSA candidates; document reasons to escalate to PSG per the in‑lab criteria list.

Step Therapy

APAP trial may substitute for a second‑night titration when split‑night not completed

When split‑night criteria are not met, a trial of APAP (E0601) may be used instead of a second in‑lab titration night per the General Guidelines; the decision between repeat in‑lab titration and immediate APAP is determined by those guidance rules and documented clinical rationale.

If split‑night cannot be completed, document why and whether APAP at home (E0601) is being used as the alternative, with rationale and prior trial data as appropriate.

Step Therapy

When split‑night fails, document rationale for second‑night titration versus home APAP

If a split‑night study cannot be completed, the choice between a second‑night in‑lab full PAP titration versus immediate home APAP (E0601) should follow the policy's general at‑home versus in‑lab guidance and be documented in the record.

Document diagnostic findings, reasons split‑night failed, and rationale for selecting second‑night titration vs immediate APAP treatment.

Step Therapy

PAP trial (≥3 months) and documentation required before HGNS evaluation

For hypoglossal nerve stimulator (HGNS) evaluation, candidates should have attempted PAP therapy (minimum three‑month trial) and appropriate prior diagnostic testing (HSAT or PAP trial) as required by the HGNS pre‑implant criteria; document PAP optimization and intolerance details.

Document minimum 3‑month PAP trial with measures of adherence/optimization and the reasons for persistent intolerance or inadequate response.

Documentation Required

Document PAP optimization efforts and objective data before declaring PAP failure

Document that PAP therapies and nocturnal oxygen (when applicable) were attempted and optimized (mask fittings, pressure adjustments, education) before declaring PAP failure for device pathway decisions; include objective PAP download data when available.

Optimization steps should be clearly described in the record; include machine downloads showing adherence/effectiveness when available.

Note

Plan‑determined management: verify health plan step therapy rules

Management details including any plan‑level step therapy are determined by the applicable health plan; the presence of codes in this guideline does not establish step therapy requirements or replace plan rules.

Verify plan‑specific step therapy or management rules prior to submission.

Step Therapy

Require trial of CPAP/APAP before initiating bilevel PAP for many indications

For some indications (e.g., OSA), CPAP/APAP (E0601) must be tried and proven ineffective or not tolerated before initiating bilevel devices (E0470/E0471); document the CPAP/APAP trial and reasons for failure or intolerance.

Include documentation of CPAP/APAP trial duration, adherence, optimization steps, and objective downloads showing inadequate control or intolerance.

Step Therapy

ASV initiation requires prior consideration of OSA/CPAP and HFrEF documentation when applicable

Before initiating ASV, demonstrate that OSA and CPAP treatment have been considered and, where listed, ruled out; for ASV in HFrEF document benefits/risks discussion, sleep medicine oversight, and follow‑up plan.

Document prior CPAP consideration/trial and rationale for ASV selection, including specialist involvement and follow‑up arrangements for HFrEF patients.

Step Therapy

PAP trial (≥1 month) required prior to oral appliance unless contraindicated/intolerant

A trial of PAP for a minimum of one month is required before custom oral appliance approval unless PAP is contraindicated or the patient is intolerant; document the PAP trial, intolerance/contraindication, or patient preference with AHI <30 when applicable.

Provide face‑to‑face documentation and evidence of PAP trial or contraindication to support oral appliance authorization.

Step Therapy

Step therapy / repeat testing: repeat PSG not routine for resolved symptoms or uncomplicated parasomnias

Repeat PSG is not routinely supported for resolved symptoms after adenotonsillectomy or for uncomplicated typical parasomnias without concern for SDB; authorization for repeat testing must document a significant clinical change or other policy‑listed triggers.

Document specific clinical changes (e.g., ≥10% weight change, new cardiac/neurologic events, return of symptoms) when requesting repeat testing.

Note

No step therapy rules in reference‑only sections

No step therapy rules are provided in the policy reference‑only sections; plan‑specific step therapy must be confirmed with the applicable health plan.

Reference pages in the document do not specify step therapy.

Documentation Required

Document comprehensive clinical evaluation and prior study‑search efforts before sleep testing

Providers must document a current comprehensive clinical evaluation (face‑to‑face or telehealth) including sleep symptoms or sufficient history to complete a validated questionnaire, a focused physical exam (cardiopulmonary exam, obesity level, neck circumference, oropharyngeal exam), relevant prior diagnostic studies, and relevant labs (ABG or serum bicarbonate within one year) before a sleep study is considered medically necessary.

Physical exam elements should include cardiopulmonary evaluation, level of obesity, neck circumference, and oropharyngeal findings (e.g., Friedman/Mallampati).
Attempt to obtain prior sleep study results must be documented (contact prior facility/provider, DME supplier, or request from patient).

Documentation Required

Document specific clinical justification for in‑lab PSG per listed reasons

Clinical documentation submitted for in‑lab PSG requests must support a listed reason for in‑lab testing (e.g., validated questionnaire results, inability to safely use HSAT, prior inadequate HSAT with report submitted, or specific comorbid diagnoses as enumerated in the policy).

When citing prior HSAT inadequacy include the HSAT report demonstrating <4 hours of oximetry/flow or other technical failures.
For comorbid conditions, include objective data (e.g., CO2 or ABG values, PFTs, echocardiography) as required by the policy.

Documentation Required

Technical/scoring requirements: follow AASM standards; HSAT device specifications required

PSG and HSAT studies and scoring must follow the AASM Manual for Scoring of Sleep and Associated Events; HSAT devices must be FDA‑cleared, have unique identifiers, record oximetry and heart rate, allow raw data review, and calculate an REI/AHI per monitoring time.

Ensure HSAT device meets CPT definitions and provides raw data for review/editing and REI/AHI calculation.
PSG (Type I) must include EEG, EOG, chin/leg EMG, airflow, effort, oxygen saturation, ECG, synchronized video, and allow AHI/RDI calculation.

Documentation Required

Document reasons for in‑lab PSG: HSAT inadequacy, inability to use HSAT, or qualifying comorbidities with objective data

Clinical documentation for in‑lab PSG must show inability to use HSAT safely, failed or technically inadequate HSAT (include prior report), or presence of specified comorbid conditions meeting numeric thresholds (e.g., BMI, CO2/ABG, PFTs) to justify in‑lab testing.

Technically inadequate HSAT is defined as lacking at least 4 hours of oximetry and flow data — include the HSAT report if citing inadequacy.
For obesity/hypoventilation include BMI and CO2/ABG or serum bicarbonate data per policy thresholds.

Documentation Required

Attach prior study report and document change‑in‑status for repeat testing or titration requests

When requesting repeat testing or titration, submit the prior sleep study report and document the significant change in clinical status prompting reevaluation (examples include ≥10% weight change, new/worsening symptoms, post‑surgical changes, or inadequate prior testing).

If prior study is unavailable, document reasonable attempts to obtain it; absence of documented effort risks denial.
Include PAP download data to document adherence when required for reassessment decisions.

Documentation Required

Documented effort to obtain unavailable prior sleep study reports is required

If prior sleep testing results are unavailable, the request must document efforts made by the ordering provider to obtain those results (contacting the prior testing facility/provider, previous DME supplier, or asking the patient for a copy) before authorization will be considered.

Document dates and contacts attempted to retrieve prior study reports to meet the policy requirement.

Documentation Required

Prior sleep study report required when prior results are used to qualify for repeat testing or device pathways

When criteria reference results of a prior PSG or HSAT (for example prior AHI, percent central apneas), the prior sleep study report must be submitted to establish eligibility for repeat testing, device consideration, or therapy pathways.

Attach the prior report showing the specific indices (AHI/REI/central events) cited in the request.

Documentation Required

Post‑implant retesting: document prior inadequate tests and timing; initial tuning PSG allowed ≥2 months post‑implant

For post‑implantation PSG used to titrate devices (HGNS/TPNS), document prior inadequate sleep tests (limited sleep time or other variables) and provide justification for repeat testing; initial post‑implant studies are allowed at specified intervals (typically ≥2 months).

Provide prior testing reports if claiming prior inadequacy; document timing relative to implantation and the clinical need for retuning.

Documentation Required

Submit valid diagnostic test results (indices + symptoms/comorbidities) before ordering PAP devices

Valid diagnostic testing demonstrating a positive diagnosis is required to determine type and severity (AHI/RDI/REI and symptom/comorbidity documentation) before ordering PAP devices or other device therapies.

Ensure results document indices and that symptom/comorbidity criteria are recorded per definitions for OSA, CSA, TECSA, or hypoventilation.

Documentation Required

Document diagnosis, ordering evaluation, instructions/education, and mask refitting when ordering PAP devices

For device orders and instruction (e.g., initiation of PAP), include documentation of the positive diagnosis (HSAT or PSG), record of the clinical evaluation ordering the device, instructions/education provided, and any mask refitting or adjustments performed.

Include evidence of patient education, mask fitting, and any troubleshooting steps taken during the initial trial period.

Documentation Required

Document diagnosis and specialist oversight for ASV initiation; HFrEF requires documented discussion and follow‑up plan

ASV (E0471) initiation requires documentation of the specific diagnosis (e.g., central sleep apnea, treatment‑emergent CSA, opioid‑related CSA) and supporting testing/clinical notes; for HFrEF include risks/benefits discussion, sleep specialist oversight, and follow‑up plan.

Provide prior testing showing central index and percent central events when claiming CSA indications.
Document CPAP trials and rationale for selecting ASV when relevant.

Documentation Required

Replacement device documentation: DME evaluation, non‑repairable status, and no warranty required

Replacement device requests must document device malfunction, a DME supplier physical evaluation determining the device is unrepairable, and that the device is no longer covered under warranty; failure to provide these items may trigger denial.

Include DME evaluation report and warranty status with replacement requests.
Show objective usage/adherence data and continued symptomatic improvement on therapy as required.

Documentation Required

Supply compliance data required: 30 continuous days within 6 months showing ≥4 hrs/night on 70% nights

For PAP accessory/supply requests, provide compliance data demonstrating device use ≥4 hours/night on 70% of nights with 30 continuous days of data within the prior 6 months; requests must also meet HCPCS code‑specific frequency and compatibility rules.

Submit 30 consecutive days of compliance data from within 6 months prior to the request.
Confirm requested supplies meet the frequency limits and do not conflict with other ordered masks/tubing per code rules.

Documentation Required

Provide 30 consecutive days of compliance data (within 6 months) when requesting PAP supplies

Compliance data for PAP supplies must consist of 30 continuous days of device usage within the prior 6 months showing use ≥4 hours/night on 70% of nights; include machine download or monitoring reports with the authorization request.

Provide the date range of the 30 continuous days and the device report showing adherence metrics.
Include explanation if data are unavailable or inconsistent.

Documentation Required

Oral appliance documentation: face‑to‑face visit, positive study, PAP intolerance/contraindication, and dentist provider

For oral appliance requests, document a face‑to‑face visit, a positive diagnostic sleep study, documentation of PAP intolerance or contraindication (or patient preference with AHI <30), and that a qualified licensed dentist will provide and follow up on the custom device.

Attach the diagnostic sleep study report and record of the face‑to‑face visit with the ordering medical provider.
Include documentation of PAP trial duration and intolerance interventions when applicable.

Documentation Required

Initial pediatric PSG documentation: symptoms and supporting findings required

Initial pediatric in‑lab full‑night diagnostic PSG authorization must document the pediatric symptoms suggestive of sleep‑related breathing disorder (e.g., snoring, witnessed apnea, behavioral problems, daytime sleepiness) and one of the specified supporting findings when indicated (e.g., tonsillar hypertrophy, failure to thrive).

Provide age, presenting symptoms, and relevant physical findings tied to pediatric PSG indications.

Documentation Required

Document reason(s) for split‑night testing in pediatric PSG requests

When performing split‑night PSG in pediatrics, document the clinical reason(s) for performing a split‑night study in the pediatric record to support authorization and medical necessity.

Describe why split‑night was chosen and how split‑night criteria apply in the pediatric case.

Documentation Required

Repeat PAP titration in pediatrics: document growth‑related changes or recurrent symptoms

For repeat PAP titration requests in children, document growth‑related changes (e.g., somatic growth) or recurrent symptoms prompting reevaluation of CPAP settings to justify retitration.

Provide growth charts or clinical notes showing changes and describe impact on PAP therapy settings.

Documentation Required

Submit prior study results with authorization requests for additional sleep studies

Submit results of prior studies when requesting authorization for additional studies; reviewers require prior reports to assess medical necessity for further testing.

Attach prior PSG/HSAT reports to the authorization request to avoid delays or denials.

Documentation Required

Attach prior sleep study report when prior results are cited in criteria

Provide the prior study report when criteria reference prior results (e.g., prior AHI, percent central events); the prior report is required to establish eligibility for repeat testing or device consideration.

Clearly identify the indices from the prior report used to justify the current request.

Note

Cite and follow referenced CMS LCDs for additional documentation/coverage rules

The policy cites specific CMS LCDs (L33718, L33800, L35050) that contain documentation and coverage requirements; providers should follow those LCDs in addition to this policy when applicable.

Check the LCDs for any local coverage rules or prior authorization steps that may affect the request.

Denial Risk

Denial risk: missing current comprehensive clinical evaluation

If a sleep study request lacks a current comprehensive clinical evaluation (including sleep history, physical exam, prior studies, and relevant labs), it may be denied as not medically necessary; include the required evaluation documentation with the request.

Ensure the clinical evaluation includes sleep symptoms or sufficient history, physical exam elements, prior diagnostic studies, and ABG/serum bicarbonate when applicable.

Denial Risk

Denial risk: missing clinical justification for ordering PSG instead of HSAT

Requests for PSG instead of HSAT may be denied if none of the listed clinical criteria for in‑lab testing are documented (e.g., inability to use HSAT, prior inadequate HSAT with report, or a qualifying comorbid condition).

If requesting PSG, document which in‑lab indication applies and attach supporting data/reports.

Denial Risk

Denial risk: technically inadequate HSAT without supporting report

Technically inadequate HSAT recordings (lacking a minimum of 4 hours of oximetry and flow data) may be considered inadequate for coverage decisions and prompt the need for in‑lab PSG; include the HSAT report showing the inadequacy when requesting escalation.

Attach the HSAT report demonstrating <4 hours of valid oximetry/flow data to justify in‑lab testing.

Denial Risk

Denial risk: adequate HSAT but no documented in‑lab indication

If an HSAT is technically adequate (minimum 4 hours oximetry and flow) and no listed in‑lab indication is documented, requests for PSG may be denied; ensure in‑lab indications are explicitly stated and supported.

Document comorbidities or other policy criteria that warrant in‑lab testing when HSAT is adequate.

Denial Risk

Denial risk: repeat diagnostic testing solely to supply new equipment

Repeat diagnostic testing requested solely to supply new PAP equipment or another new treatment modality without a significant change in clinical status risks denial as not medically necessary.

Provide evidence of clinical change (e.g., ≥10% weight change, return of symptoms, new cardiac/neurologic events) to support repeat testing.

Denial Risk

Denial risk: repeat titration solely to supply new equipment or without clinical change

Repeat titration requests submitted only to supply new PAP equipment or to assess PAP efficacy without a significant clinical change or documented adherence may be denied; show prior adherence and a qualifying trigger for retitration.

Document PAP adherence (≥4 hrs/night on 70% of nights) and the clinical change prompting retitration.

Denial Risk

Denial risk: prior study unavailable without documented effort to obtain it

When a prior sleep study report is unavailable, requests for repeat testing must include documentation of a reasonable effort by the requesting provider to obtain the prior report; absence of such documentation risks denial.

Document contacts or attempts made to retrieve prior study reports (facility, provider, DME supplier, patient).

Denial Risk

Denial risk: orders not placed by an authorized treating medical provider

Orders for PAP devices and supplies can only be placed by a treating medical provider (MD, DO, NP, Clinical Nurse Specialist, or PA); requests submitted by non‑authorized ordering providers risk denial.

Ensure the order is signed/placed by an authorized treating medical provider as defined in the policy.

Denial Risk

Denial risk: missing DME evaluation/warranty evidence for replacement device requests

Replacement device requests require documentation that the device is not operating, has been evaluated by the DME supplier and found unrepairable, and is no longer under warranty; failure to provide these items may trigger denial.

Attach DME supplier evaluation and warranty status with replacement requests.
Provide evidence of continued therapy benefit and objective adherence data.

Denial Risk

Denial risk: replacement requests when device is operable, repairable, or under warranty

Replacement device requests risk denial if the device is still operating, has not been evaluated and found unrepairable by the DME supplier, or remains under warranty; include objective proof of device malfunction and DME assessment.

Document device serial number, malfunction description, DME repair attempt, and warranty status.

Denial Risk

Denial risk: missing compliance data for PAP accessory/supply requests

Accessory and supply requests risk denial if the required compliance data are not provided—specifically, 30 continuous days of device usage within the prior 6 months showing ≥4 hours/night on 70% of nights.

Failure to include the compliance download or date range matching 30 continuous days may result in denial.

Note

PA note: authorization of a code is not a guarantee of payment; verify plan coverage

Prior authorization of a listed code does not guarantee payment; inclusion of a code in the policy does not imply it is under management—providers must refer to the applicable health plan and member coverage for payment decisions.

Check the member's Certificate of Coverage/Evidence of Coverage for benefit details.

Denial Risk

PAP‑NAP (CPT 95807 / 95807‑52) is not covered — will be denied

CPT 95807 and 95807‑52 (PAP‑NAP) are not covered for the purpose of performing a PAP‑NAP and will be denied; do not submit authorization or claims for PAP‑NAP under these codes for this purpose.

PAP‑NAP was assessed based on limited evidence and is excluded from coverage in this policy.

Billing Rule

DME code limitations: avoid CPT 94799 / HCPCS E1399 for routine PAP equipment/parts

Requests billed with unlisted or miscellaneous DME codes (CPT 94799, HCPCS E1399) for routine PAP machines or parts cannot be approved and may be denied; use specific HCPCS codes for PAP equipment and supplies per the policy.

Do not use 94799 or E1399 for routine PAP equipment/parts; provide the specific HCPCS code required by policy.

Denial Risk

Denial risk: CPT 95807/95807‑52 for PAP‑NAP not covered

Claims or authorization requests for CPT 95807 or 95807‑52 submitted to perform PAP‑NAP (daytime abbreviated cardiorespiratory study to improve PAP adherence) will not be covered and are at risk of denial under this policy.

Alternative adherence strategies should be documented; do not submit PAP‑NAP claims expecting coverage.

Note

CMS LCDs may influence coverage — verify LCD criteria for device/study authorization

References to CMS Local Coverage Determinations (L33718, L33800, L35050) indicate external coverage rules may affect benefit determinations and potential denials if LCD criteria are not met; verify LCD requirements for device and study authorization.

Confirm any LCD‑specific documentation or local prior authorization steps in addition to this policy.

Note

Coding — Procedure and DME Codes

Codes referenced for bi-level PAP devicesHCPCS

E0470	Bi-level positive airway pressure, non-carc, auto-adjusting (documented in policy as bi-level PAP)
E0471	Bi-level positive airway pressure, fixed (documented in policy as bi-level PAP)

Home sleep apnea testing (HSAT) HCPCS codesHCPCS

G0398	Home sleep study (HSAT) with type II portable monitor, unattended
G0399	Home sleep test (HSAT) with type III portable monitor, unattended
G0400	Home sleep test (HSAT) with type IV portable monitor, unattended

PSG and attended/unattended sleep study CPT codesCPT

95800	Sleep study, unattended, simultaneous recording
95801	Sleep study, unattended, simultaneous recording, minimum channels
95806	Sleep study, unattended, simultaneous recording (note: do not report with certain codes)
95805	Sleep study, simultaneous recording of ventilation, respiratory effort (MSLT/MWT)
95807	Sleep study with PAP titration (may be considered experimental/investigational when used to request a PAP-NAP)
95808	Polysomnography; sleep staging with 1-3 additional parameters, attended
95810	Polysomnography; age 6+, sleep staging with 4+ additional parameters, attended (in-lab full night diagnostic)
95811	Polysomnography; age 6+, with initiation of CPAP/Bi-level ventilation, attended (split-night or titration)
95782	Polysomnography, younger than 6 years, sleep staging with 4+ parameters, attended (full night diagnostic)
95783	Polysomnography, younger than 6 years, with initiation of CPAP/Bi-level ventilation, attended (PAP titration)

Titration PAP devices requestedHCPCSCovered

E0470	Bilevel positive airway pressure, without backup rate
E0471	Bilevel positive airway pressure, with backup rate

APAP/CPAP deviceHCPCS

E0601

Continuous Positive Airway Pressure (CPAP) device, used for apnea treatment (APAP referenced as a therapy option)

Referenced PSG/MSLT CPT codesCPT

95810	Polysomnography; sleep staging with initiation of CPAP, bi-level, or other positive airway pressure therapy
95811	Polysomnography; multiple sleep latency or maintenance of wakefulness testing

Referenced PAP device HCPCS codesHCPCS

E0601	Continuous positive airway pressure (CPAP) device, autotitrating (APAP)
E0470	Bi-level positive airway pressure device, spontaneous/timed, single level or bilevel
E0471	Bi-level positive airway pressure device, spontaneous/timed, with backup rate

Bi-level PAP HCPCS referenced for titration requestsHCPCS

E0470	Bi-level PAP, S/T mode
E0471	Bi-level PAP, other modes

PAP device HCPCSHCPCS

E0601	Continuous airway pressure (CPAP/APAP) device
E0470	Respiratory assist device, bi-level pressure (BPAP) capability, WITHOUT backup rate feature, used with noninvasive interface
E0471	Respiratory assist device, bi-level pressure (BPAP) capability (including ASV), WITH backup rate feature, used with noninvasive interface
E0472	Respiratory assist device, bi-level pressure (BPAP) capability, WITH backup rate feature, used with invasive interface (e.g., tracheostomy tube)
E0561	Humidifier, non-heated, used with PAP device

PAP interfaces and supplies HCPCSHCPCS

E0562	Humidifier, heated, used with PAP device
A4604	Tubing with heating element
A7027	Combination oral/nasal mask
A7028	Replacement oral cushion combo mask
A7029	Replacement nasal pillow comb mask
A7030	CPAP full face mask
A7031	Replacement facemask interface
A7032	Replacement nasal cushion
A7033	Replacement nasal pillows
A7034	Nasal interface (mask or cannula type) used with PAP device

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Monitoring and management codesmixed

A9279	Monitoring feature/device, stand-alone or integrated (compliance/data download)
94660	CPAP initiation and management (initiation and instruction)

Covered HCPCS for CPAP/APAPHCPCSCovered

E0601

Continuous positive airway pressure (CPAP) or Auto-adjusting positive airway pressure (APAP)

Covered HCPCS for bilevel (spontaneous)HCPCSCovered

E0470

Bi-level positive airway pressure, spontaneous mode

Covered HCPCS for bilevel STHCPCSCovered

E0471

Bi-level positive airway pressure, spontaneous/timed or with backup rate (ST)

ASV deviceHCPCSCovered

E0471

Adaptive servo ventilation (ASV) device

PAP devices (CPAP/APAP/Bilevel)HCPCSCovered

E0470	Bilevel PAP device
E0601	CPAP device

HumidifiersHCPCSCovered

E0562	Heated humidifier, initial setup
E0561	Non-heated humidifier, initial setup

PAP masks and partsHCPCSCovered

A7027	Combination oral/nasal mask, used with PAP, each
A7028	Oral cushion used with combination oral/nasal mask, replacement only
A7029	Nasal pillows used with combination oral/nasal mask, replacement only, pair
A7030	Full face mask used with PAP, each
A7031	Full face mask interface replacement, each
A7034	Nasal interface (mask or cannula type) used with PAP, each
A7032	Cushion for use on nasal mask interface, replacement only, each
A7033	Nasal pillow for use on nasal cannula type interface, replacement only, pair
A7044	Oral interface used with PAP, each
A7035	Headgear used with PAP, each

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Physician PAP service (face-to-face)CPTCovered

94660

Physician application or adjustment of mask or pressure titration or PAP related service

PAP accessories and supplies (HCPCS)HCPCSCovered

A7027	Combination oral/nasal mask, used with PAP, each
A7028	Oral cushion used with combination oral/nasal mask, replacement only
A7029	Nasal pillows used with combination oral/nasal mask, replacement only, pair
A7030	Full face mask used with PAP, each
A7031	Full face mask interface replacement, each
A7034	Nasal interface (mask or cannula type) used with PAP, each
A7032	Cushion for use on nasal mask interface, replacement only, each
A7033	Nasal pillow for use on nasal cannula type interface, replacement only, pair
A7044	Oral interface used with PAP, each
A7035	Headgear used with PAP, each

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Oral appliance treatment codesHCPCS

E0485	Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting
E0486	Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment
A9270	Non-covered item or service (e.g., oral appliances that do not meet policy criteria, tongue-retaining devices, devices used only for snoring)
K1027	Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting

Not Covered CPT CodesCPTNot Covered

95807	PAP-NAP (daytime abbreviated cardiorespiratory sleep study) - referenced as not covered for this purpose
95807-52	PAP-NAP with modifier - referenced as not covered for this purpose

DME Exclusions / Not ApprovedCPT|HCPCSNot Covered

94799	Unlisted pulmonary service or procedure (cannot establish medical necessity due to presence of more specific codes)
E1399	Miscellaneous DME items (not approved for routine PAP equipment/supplies)

Not Covered CPT Codes for PAP-NAPCPTNot Covered

95807	PAP-NAP (daytime abbreviated cardiorespiratory sleep study) — not covered for the purpose of performing PAP-NAP
95807-52	PAP-NAP with modifier -52 — not covered for the purpose of performing PAP-NAP

Referenced CMS Local Coverage Determinationsmixed

L33718	LCD - Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
L33800	LCD - Respiratory Assist Devices
L35050	LCD - Outpatient Sleep Studies

inv-110: Diagnostic thresholds

OSA diagnostic thresholdAHI/RDI/REI ≥15 events/hour OR AHI/RDI ≥5 and <15 events/hour with qualifying symptoms or comorbidities

Symptomatic lower-thresholdAHI/REI ≥5 and <15 with documented sleepiness, awakenings with gasping/choking, bed‑partner reports, or comorbidities (hypertension, CAD, CHF, AF, T2DM, stroke)

Pediatric severity referencePediatric severity categorized separately (mild 1–<5; moderate ≥5–<10; severe ≥10 events/hr)

inv-111: PCO2 and bicarbonate thresholds

Awake CO2 threshold (ABG/EtPCO2/TcPCO2)PCO2 ≥45 mmHg

Venous blood gas thresholdVBG PCO2 ≥50 mmHg

Serum bicarbonate screeningSerum bicarbonate ≥27 mmol/L suggests need for PaCO2 measurement to evaluate OHS

inv-112: BMI thresholds

OHS BMI thresholdBMI ≥30 kg/m2 (defines obesity hypoventilation syndrome when combined with qualifying CO2 criteria)

PSG obesity consideration thresholdBMI ≥45 may prompt in‑lab PSG rather than HSAT

HGNS BMI limit referenceHGNS pre‑implant candidates: BMI ≤40 per device pathway (contextual reference)

inv-113: BMI thresholds for PSG

PSG indicated for high BMIBMI ≥45 OR BMI ≥30 with elevated awake PCO2 (ABG/EtPCO2/TcPCO2 ≥45 or VBG PCO2 ≥50) or serum bicarbonate ≥27

OHS confirmationIn individuals with obesity, OHS must be confirmed by awake ABG/EtPCO2/TcPCO2 ≥45 or VBG PCO2 ≥50

BMI for OHSBMI ≥30 used to define OHS when CO2 criteria met

inv-114: Minimum HSAT data

Minimum HSAT technical adequacyHSAT is technically inadequate if recordings lack a minimum of 4 hours of oximetry and flow data

HSAT device requirementsHSAT devices must be FDA‑cleared, record oximetry and heart rate, display raw data, and calculate REI/AHI

HSAT scoring limitsRDI cannot be derived from HSAT because RERAs are not scored on HSAT

inv-115: Obesity hypoventilation syndrome (OHS) criteria

OHS core criteriaBMI ≥30 kg/m2 PLUS awake ABG/EtPCO2/TcPCO2 with PCO2 ≥45 OR venous blood gas PCO2 ≥50 mmHg

Alternative screeningSerum bicarbonate ≥27 mmol/L can prompt further PCO2 measurement to evaluate for OHS

Clinical qualifiers for OHSAdditional qualifiers include recent hospitalization with persistent awake hypoventilation or persistent hypoventilation despite compliant PAP

inv-116: Pulmonary disease severity

Pulmonary function thresholdFEV1 ≤69% predicted indicates moderate to severe obstructive pulmonary disease

ABG oxygen/CO2 thresholdsDocumented ABG showing PO2 <60 mmHg or PCO2 ≥45 mmHg supports need for in‑lab PSG

Nocturnal oxygen useUse of nocturnal oxygen is a marker for moderate to severe pulmonary disease warranting in‑lab testing

inv-117: Split-night study thresholds

Split-night dual criteriaDiagnostic AHI ≥15/hr during ≥2 hours of recording AND at least 3 hours available for PAP titration

Diagnostic recording durationRequire ≥2 hours of diagnostic recording meeting AHI threshold to consider split‑night

Titration time requirementAt least 3 hours must remain available for PAP titration during the same night

inv-118: Split-night AHI threshold

AHI threshold for split-night decisionAHI ≥15 events per hour during the diagnostic portion (measured over ≥2 hours)

Context noteApplies to in‑lab PSG diagnostic portion when considering immediate PAP titration

AASM alignmentThis split‑night approach is the AASM‑recommended method when criteria are met

inv-119: Split-night titration time

Minimum titration time on split-night≥3 hours available for PAP titration during the same night

Practical implicationIf ≥3 hours are not available, a subsequent full‑night titration or home APAP trial may be required

AASM recommendationSplit‑night preferred when both diagnostic AHI and titration time criteria are satisfied

inv-120: PAP adherence threshold

PAP adherence definitionUse of PAP ≥4 hours per night on 70% of nights during a consecutive 30‑day period

Establishing compliance windowCompliance window may occur anytime during the first 3 months for initiation metrics

Supply/continuation requirement30 continuous days of compliance data within the prior 6 months typically required for supply approvals

inv-121: Weight change threshold for retesting

Weight change trigger for retestingWeight increase or decrease ≥10% may prompt repeat diagnostic testing or retitration

Post‑bariatric timingAt least 3 months after bariatric surgery when there is >10% weight loss to reassess OSA

Effect on management≥10% weight change considered significant if test results would alter clinical management

inv-122: PAP adherence threshold (repeat)

PAP adherence for repeat titrationDocumented use ≥4 hours/night on 70% of nights during a consecutive 30‑day period required before repeat titration is considered (unless exception applies)

Evidence sourceRequired adherence evaluated via device download within prior 6 months (30 continuous days preferred)

Exception noteIf adherence cannot be demonstrated but significant clinical change exists (e.g., recent stroke), repeat titration may still be considered with documentation

inv-123: Weight change threshold

Weight change threshold prompting retitrationIncrease or decrease in weight ≥10% with return of or intolerance to therapy may justify repeat titration

ApplicabilityApplies to individuals on CPAP, bilevel, APAP, or ASV when clinical status changes

Documentation requirementPrior device download and prior study reports should be provided to support the request

inv-124: AHI thresholds summary

Summary AHI thresholdsDiagnostic thresholds: AHI/RDI/REI ≥15 events/hr; AHI/RDI/REI ≥5 and <15 requires symptoms or comorbidity to diagnose OSA

Remede pivotal trial notePivotal Remede® trial used AHI ≥20/hr for inclusion and central AI ≥50% with ≥30 central events as central‑dominant criteria

Oral appliance capOral appliance may be used for patient preference when AHI/RDI/REI <30 with appropriate documentation

inv-125: Age and BMI notes

Adult age criterionMany pre‑treatment and repeat testing criteria apply to individuals aged ≥18 years

BMI recurring roleBMI ≥30 frequently used as a qualifier for repeat testing or OHS evaluation; BMI ≥45 prompts in‑lab PSG consideration

Pediatric separate rulesPediatric thresholds and criteria differ and are applied for individuals ≤17 years

Definitions and Background

Sleep‑disordered breathing encompasses a spectrum of conditions including obstructive sleep apnea (OSA), central sleep apnea (CSA), treatment‑emergent CSA, and sleep‑related hypoventilation. Diagnosis requires both a comprehensive clinical evaluation and valid sleep testing (HSAT or attended in‑lab PSG) to quantify indices such as AHI/RDI/REI and to verify symptom correlation.

inv-212: Obstructive sleep apnea (OSA) definition

OSA diagnostic definitionOSA defined by valid testing with AHI/RDI ≥15 events/hr OR AHI/RDI ≥5 and <15 with qualifying symptoms or comorbidities

AHI/RDI measurement contextsOn PSG use AHI or RDI; on HSAT use AHI or REI (REI is AHI surrogate on HSAT)

Clinical requirement for milder AHIWhen AHI/RDI 5–<15, documentation of symptoms (sleepiness, gasping, partner report) or listed comorbidities is required

inv-213: Central sleep apnea (CSA)

CSA diagnostic criteriaPresence of sleep‑related symptoms PLUS central apnea/central hypopnea index ≥5/hr with central events >50% of total apneas/hypopneas

Symptoms listSymptoms include sleepiness, difficulty initiating/maintaining sleep, awakening short of breath, or witnessed apneas

Cheyne‑Stokes contextCheyne‑Stokes breathing requires CSA criteria plus known AF/flutter, CHF, or neurologic disorder with crescendo–decrescendo pattern

inv-214: Treatment-emergent central sleep apnea

TECSA diagnostic elementsSymptoms attributable to central events with AHI/REI ≥5/hr AND PSG during PAP (without backup rate) showing resolution of obstructive events and central index ≥5/hr with central events >50%

PAP testing requirementPSG during PAP (no backup rate) must show significant resolution of obstructive events to meet TECSA definition

Clinical implicationTECSA is an indication considered for ASV when criteria met

inv-215: Sleep-related hypoventilation definition

Hypoventilation duration and magnitudeSleep‑related hypoventilation: PCO2 >55 mmHg for ≥10 minutes OR ≥10 mmHg increase to >50 mmHg for ≥10 minutes during sleep

Measurement methodsPCO2 may be arterial, transcutaneous, or end‑tidal measurements per guidance

Clinical useHypoventilation criteria guide need for in‑lab testing and potential bilevel/ventilatory support

inv-217: Obesity hypoventilation syndrome (OHS) definition

OHS definition (core)BMI ≥30 kg/m2 PLUS awake ABG/EtPCO2/TcPCO2 PCO2 ≥45 OR VBG PCO2 ≥50 mmHg

Serum bicarbonate roleSerum bicarbonate ≥27 mmol/L can screen for OHS; values <27 effectively rule out hypercapnia when pretest probability low–moderate

Additional qualifiersOHS confirmation may require clinical qualifiers (recent hospitalization with persistent awake hypoventilation, or persistent hypoventilation despite compliant PAP)

inv-218: PSG / Type I monitoring definition

PSG / Type I monitoring componentsAttended in‑lab polysomnography includes EEG, EOG, chin/leg EMG, airflow, respiratory effort, oxygen saturation, ECG and synchronized video

Calculated indicesPSG allows calculation of AHI and RDI (RDI includes RERAs and requires PSG)

Scoring standardScoring should follow the AASM Manual for the Scoring of Sleep and Associated Events

inv-219: HSAT / Home Sleep Apnea Testing definition

HSAT definition and minimum featuresUnattended home testing that must be FDA‑cleared, record oximetry and heart rate, allow raw data review, and calculate REI/AHI based on monitoring time

HSAT limitationsHSAT cannot score RERAs; therefore RDI cannot be derived from HSAT

Technical adequacy for coverageHSAT recordings must include a minimum of 4 hours of oximetry and flow data to be considered technically adequate

inv-220: AHI and RDI definitions

AHI definition (PSG)AHI = apneas and hypopneas per hour of sleep (derived from PSG)

RDI definitionRDI = apneas, hypopneas, and RERAs per hour of sleep (requires PSG)

REI on HSATOn HSAT, REI (respiratory event index) approximates AHI based on monitoring time or estimated sleep

inv-221: Split night study

Split-night study definitionSingle‑night PSG that includes both diagnostic and PAP titration portions; medically necessary when diagnostic AHI ≥15/hr over ≥2 hours and ≥3 hours remain for titration

Typical applicationSplit‑night is recommended per AASM when criteria are met to complete diagnosis and titration in one night

Requirement linkageSplit‑night requires both diagnostic threshold and available titration time to be met

inv-222: Titration study definition

Titration study definitionIn‑lab full‑night PAP titration performed when PAP (CPAP/APAP) has failed or is intolerable, or for central apnea, hypoventilation syndromes, severe COPD, or neuromuscular disease

Bilevel device linkageBilevel PAP (HCPCS E0470/E0471) titration is used when CPAP/APAP ineffective or not tolerated or for specified disorders

APAP trial considerationA trial of APAP (E0601) ≥30 days with objective data may be expected prior to in‑lab titration for some indications

inv-224: Titration study definition

MSLT requirement relative to PSGMSLT must immediately follow a PSG; MSLT cannot follow a split‑night or PAP titration study where pressures were adjusted

Adequate prior sleepSufficient sleep must be demonstrated for specified age-based durations prior to MSLT (adults ≥7 hrs; adolescents ≥8 hrs; children ≥9 hrs)

Exclusion of other causesExcessive sleepiness must not be better explained by OSA or other conditions prior to MSLT

inv-225: MWT definition

MWT purpose and protocolMaintenance of Wakefulness Test (40‑minute protocol) to measure ability to stay awake; indicated when diagnosed disorder with excessive sleepiness and stable on effective treatment

PAP adherence for MWTIf on PAP, device download must show AHI <5/hr and use ≥4 hours/night on 70% of nights during a consecutive 30‑day period

Use casesPerformed when objective documentation of wakefulness is needed for safety or lack of reliable history

inv-226: PAP adherence definition

PAP adherence definitionPAP adherence = use ≥4 hours per night on 70% of nights during a consecutive 30‑day period

Purpose of adherence metricUsed to determine adequacy before repeat titration, continuation of device coverage, and supply approvals

Compliance data window30 continuous days of compliance data within 6 months prior to request are typically required

inv-227: Sher's criteria (surgical success)

Sher's surgical success criteriaReduction in baseline AHI by ≥50% with a final AHI <20 events/hour (used in HGNS outcome reporting)

HGNS indication contextHGNS trials used AHI thresholds (e.g., AHI 20–50 in STAR) and BMI limits in candidate selection

Long‑term outcomesHGNS showed sustained reductions in AHI and oxygen desaturation indices at 12 months and beyond in trials

inv-228: Remede® System / TPNS definition

TPNS / Remede® system definitionAn implanted neurostimulator and sensing/stimulation lead placed transvenously to stimulate a phrenic nerve to improve ventilatory effort for central sleep apnea

Post‑implant testing timingPost‑implant PSG for device tuning is medically necessary at least 2 months after implantation

Trial device pathwayTPNS candidacy requires prior moderate to severe CSA and exclusion of opioid‑attributed CSA and recent stroke/TIA among other criteria

inv-229: AHI thresholds (definition context)

AHI thresholds contextAHI ≥15/hr commonly used to define moderate‑to‑severe disease for inclusion and repeat‑testing criteria; pivotal TPNS/Remede trials used AHI ≥20/hr for inclusion in some studies

Central‑dominant criteriaCentral AI ≥50% of apneas with ≥30 central events was used in pivotal Remede® trial inclusion criteria

Age requirement for some device pathwaysMany device pathways require age ≥18 and recent PSG (within 12 months) showing qualifying AHI thresholds

Background and Evidence

Accurate assessment of sleep‑disordered breathing combines a documented clinical evaluation — review of sleep‑related symptoms, focused physical exam, and relevant laboratory data — with appropriately selected testing. HSAT is first‑line for uncomplicated adult OSA evaluation when criteria are met; in‑lab PSG is required for higher‑risk scenarios (for example, suspected CSA, significant cardiopulmonary or neuromuscular disease, or when HSAT is technically inadequate). Clinical thresholds and test selection are defined in the policy to guide appropriate use.

Sleep Disordered Breathing Diagnosis and Treatment Guidelines (Coverage Policy)

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Coverage Criteria — Diagnostic Testing and Therapy

Provider Actions — Ordering, Documentation, and Authorization

Coding — Procedure and DME Codes

Definitions and Background

Background and Evidence

Revision History