CurrentHealthPartnersPolicy N/A

Prior authorization for attended polysomnography (in‑lab sleep study)

This document is a prior authorization request form/process for attended polysomnography to evaluate obstructive sleep apnea (OSA) and other sleep disorders for HealthPartners members; it affects ordering providers, facilities, and members requiring in-lab sleep testing.

Policy Summary

PayerHealthPartners

PolicyPrior authorization for attended polysomnography (in‑lab sleep study)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for attended polysomnography with supporting clinical documentation and any HSAT results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

95808, 95810Procedure/CPT codes listed on form

Prior auth requiredIn-lab attended polysomnography

No prior authHome sleep apnea testing (HSAT)

Fax & phoneUM contact methods provided

Form ID 20-913603-913616Form identifier and date

Attended Polysomnography Coverage Criteria

Attended polysomnography authorization criteria

Covered when clinically indicated to evaluate suspected obstructive sleep apnea (OSA) or other sleep disorders, or for titration procedures; submit supporting clinical documentation and any home unattended sleep study (HSAT) results if applicable.

ALL of the following

Indication (one or more):
- Evaluation of suspected obstructive sleep apnea (OSA)
- Evaluation of a suspected sleep disorder(s) other than OSA (specify)
- Titration of oral appliance
- Titration of a hypoglossal nerve stimulator

Policy Summary

PayerHealthPartners

PolicyPrior authorization for attended polysomnography (in‑lab sleep study)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for attended polysomnography with supporting clinical documentation and any HSAT results.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization & Provider Requirements

Prior Authorization

Prior authorization required for attended polysomnography

Submit a prior authorization request for attended (in‑lab) polysomnography. Include supporting clinical documentation and any home unattended sleep study (HSAT) report with interpretation when applicable. If the member’s condition would be seriously jeopardized by waiting the standard review time, indicate urgency and provide the clinical reason for urgency on the form.

Fax completed forms to (952) 853-8712 or contact Utilization Management at (952) 883-6333 for questions.
Use the proposed date of procedure field and answer whether waiting the standard review time would seriously jeopardize the member’s health, life, or ability to regain maximum functioning; if Yes, provide the clinical reason for urgency.
Include any HSAT report results with interpretation, when applicable, as part of the submitted clinical documentation.

Documentation Required

HSAT excluded from prior authorization

Home sleep apnea testing (HSAT) does not require prior authorization and should not be submitted on the attended polysomnography prior authorization form.

Key Definitions

HSAT (Home Sleep Apnea Testing) — definition and policy notes

DefinitionHome sleep apnea testing (HSAT): an unattended, home-based sleep study for evaluation of suspected obstructive sleep apnea; HSAT does not require prior authorization for HealthPartners members.

Prior authorizationNot required for HSAT (providers may proceed without submitting a prior authorization request).

DocumentationIf HSAT was performed prior to requesting in‑lab testing, include the HSAT report and interpretation with clinical documentation when submitting requests for attended polysomnography.

Attended polysomnography — definition, uses, and authorization

DefinitionAttended full‑channel polysomnography: an in‑laboratory, attended sleep study used to evaluate suspected obstructive sleep apnea (OSA) and other sleep disorders, and to perform titration procedures (eg, oral appliance or hypoglossal nerve stimulator titration).

When coveredCovered when clinically indicated for evaluation of suspected OSA, evaluation of other suspected sleep disorders, titration of oral appliances, titration of hypoglossal nerve stimulators, or repeat attended polysomnography for OSA; submit clinical documentation to support the request.

Prior authorization requirementPrior authorization is required for attended polysomnography; submit the completed prior authorization form and supporting clinical documentation (including any prior HSAT results, if applicable).

Relevant procedure codesListed CPT codes for attended polysomnography on the form include 95808 and 95810.

OpenPayer

Prior authorization for attended polysomnography (in‑lab sleep study)

Attended Polysomnography Coverage Criteria

Procedure Codes

Prior Authorization & Provider Requirements

Key Definitions

95808	Polysomnography; attended, sleep staging with 4 or more parameters of sleep, attended
95810	Polysomnography; with initiation of CPAP, or other therapy, attended