Prior authorization for attended polysomnography (in‑lab sleep study)
Customize your policy alerts
Sign up for all HealthPartners policy alerts
Know when HealthPartners releases new policies or updates existing guidance.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
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
- Repeat attended full-channel polysomnography for OSA
Submit clinical documentation to support your request; include any home unattended sleep study report results with interpretation (if applicable).
Procedure Codes
Prior Authorization & Provider Requirements
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.
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
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.