CurrentFidelis CarePolicy CP.MP.24

Multiple Sleep Latency Testing (MSLT) Coverage Criteria

Clinical coverage policy describing medical necessity criteria, repeat testing criteria, and coding guidance for Multiple Sleep Latency Testing for members/enrollees aged two years and above within Fidelis Care/Centene-affiliated health plans.

Policy Summary

PayerFidelis Care

PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria

Policy CodePolicy CP.MP.24

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating that all medical necessity criteria are met before coverage of CPT 95805.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥ 2ICSD-3 sleep onset REM periods

< 8 minICSD-3 mean sleep latency

≥ 8 wksMin EDS duration

≥ 10Epworth score

≥ 2 yrsMinimum covered age

95805Referenced CPT

Medical Necessity Criteria

Initial MSLT medical necessity

Covered when ALL of the following are met:

MSLT initial criteria: Member/enrollee age ≥ 2 years AND excessive daytime sleepiness (EDS) for ≥ 8 weeks with Epworth Sleepiness Scale score ≥ 10 AND a standard overnight polysomnogram (PSG) is planned for the night before the MSLT AND suspected idiopathic hypersomnia OR suspected narcolepsy with any of: cataplexy (brief, sudden loss of muscle tone), hypnagogic and/or hypnopompic hallucinations, or sleep paralysis AND medical conditions considered and treated if indicated AND medications deemed noncontributory AND no untreated psychiatric disorder (or psychiatric disorder is under care) AND drug and alcohol misuse excluded

Pediatric patients <11 years have additional requirements (see child-specific node).

Pediatric additional criteria

For patients age < 11 years, ALL of the following must be met in addition to the initial criteria:

Pediatric (<11) additional criteria: Consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist who ordered the MSLT AND testing conducted in a facility specializing in pediatric sleep disturbances with pediatric consultants available

Policy Summary

PayerFidelis Care

PolicyMultiple Sleep Latency Testing (MSLT) Coverage Criteria

Policy CodePolicy CP.MP.24

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating that all medical necessity criteria are met before coverage of CPT 95805.

SourceLink

On This Page

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Coding and Diagnostic Thresholds

Covered CPT CodesCPTCovered

95805

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

inv-07: Mean sleep latency — diagnostic threshold for abnormal MSLT

Mean sleep latency thresholdMean sleep latency < 8 minutes (ICSD-3 diagnostic threshold)

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

Pediatric note on latencyPrepubertal children have longer normal latencies (8–15 minutes) — thresholds may differ in children

inv-08: Duration of EDS — minimum duration required

Minimum durationExcessive daytime sleepiness present for ≥ 8 weeks

Measurement methodEDS quantified using Epworth Sleepiness Scale (score requirement detailed separately)

Context for testingDuration requirement is part of initial medical necessity criteria for ages ≥ 2 years

inv-09: Epworth Sleepiness Scale — required score threshold

Required Epworth scoreEpworth Sleepiness Scale score ≥ 10

Role in criteriaEpworth ≥ 10 is required as part of the initial medical necessity criteria for MSLT

Documenting requirementScore must be documented in prior authorization and medical record per documentation requirements

Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization required for CPT 95805 — prior authorization must demonstrate that all medical necessity criteria are met before services are rendered.

Affected code: CPT 95805 (Multiple sleep latency or maintenance of wakefulness testing)
Prior authorization must document that ALL policy criteria are met (see Policy/Criteria section I and II)

Step Therapy

No Step Therapy Specified

No step therapy or step-level requirements are specified for MSLT (CPT 95805). Providers do not need to complete a step-therapy protocol prior to requesting authorization.

No step therapy specified

Documentation Required

Required documentation must be submitted with the authorization request to support medical necessity.

Epworth Sleepiness Scale score (document score; EDS ≥ 8 weeks and Epworth ≥ 10 required)
Duration and description of excessive daytime sleepiness (EDS) symptoms (≥ eight weeks)
Results and report of prior overnight polysomnography (PSG) performed the night before the MSLT (or documentation that a PSG is planned for the night before)
Clinical notes addressing suspected diagnosis (suspected narcolepsy or idiopathic hypersomnia), presence/absence of cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis
Documentation that medical conditions were considered and treated if indicated, and that medications contributing to sleepiness were evaluated/managed
For patients <11 years: consultation note from pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist and documentation that testing will occur in a pediatric-capable facility

Denial Risk

Triggers for Denial

Authorization may be denied if required criteria or documentation are missing or if exclusions apply.

Denial risk if EDS duration is < eight weeks or Epworth Sleepiness Scale score < 10
Denial risk if no prior overnight PSG is documented or PSG was not performed/planned the night before the MSLT
Denial risk if medical, medication, psychiatric, drug or alcohol causes of sleepiness have not been evaluated or addressed
Denial risk if required pediatric specialist consultation or pediatric facility documentation is absent for patients <11 years
Denial risk if initial test was interpretable and no qualifying reason for repeat testing is provided (see repeat criteria)

Clinical Background

The multiple sleep latency test (MSLT) objectively measures an individual’s tendency to fall asleep and is the standard test for quantifying sleepiness in suspected narcolepsy or idiopathic hypersomnia. It is performed on the day following an overnight PSG and typically consists of four or five 20‑minute nap opportunities at two‑hour intervals while recording EEG and related parameters. Abnormal results include a mean sleep latency < 8 minutes and the presence of two or more sleep‑onset REM periods, findings that support a diagnosis of narcolepsy; very short latencies (e.g., <5 minutes) indicate marked sleepiness or severe sleep deprivation. In children, normative latencies may be longer (approximately 8–15 minutes), and testing and interpretation should account for developmental differences.

Key Definitions and Abnormal Values

inv-15: Excessive Daytime Sleepiness (EDS) — Epworth ≥10 and present ≥8 weeks

Definition of EDS for policyExcessive Daytime Sleepiness defined as Epworth Sleepiness Scale score ≥ 10 and present for ≥ 8 weeks

Age applicabilityApplies to members/enrollees age ≥ 2 years as part of initial criteria

Documentation expectationEpworth score and duration must be documented for prior authorization and clinical review

inv-16: MSLT abnormal values — Mean sleep latency <8 minutes and ≥2 SOREMPs indicate narcolepsy; pediatric notes

MSLT abnormal criteria for narcolepsyMean sleep latency < 8 minutes AND ≥ 2 sleep-onset REM periods (SOREMPs) per ICSD-3 indicate narcolepsy

Severely abnormal latencyMean sleep latency < 5 minutes is distinctly abnormal and supports narcolepsy or severe sleep deprivation

Pediatric considerationsPrepubertal children tend to have longer latencies (8–15 minutes); pediatric norms may alter interpretation

Testing contextMSLT performed the day after an overnight PSG to ensure valid results; PSG should not show significant sleep pathology