ModifiedKaiser PermanentePolicy N/A

Sleep_Studies

Clinical review criteria governing medical necessity and coverage for attended in-lab polysomnography, home sleep apnea testing (HSAT/HST), titration studies, daytime sleep studies (MSLT/MWT), abbreviated daytime studies (PAP-Nap), and actigraphy for Kaiser Foundation Health Plan of Washington members (Medicare and non‑Medicare distinctions noted).

Policy Summary

PayerKaiser Permanente

PolicySleep_Studies

Policy CodePolicy N/A

Change TypeMaterial revisions to in‑lab PSG/titrationmerged actigraphy criteria

Effective DateSep 1, 2024

Next Review Date

Key ActionWhen requesting these services, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

MPC approved to adopt criteria for Sleep Studies; effective date 09/01/2024 and 60-day notice required.

MPC approved proposed criteria update to in‑center sleep studies, effective 07/01/2026 with 60‑day notice.

HSATHome Sleep Apnea Testing (HSAT) - Medical necessity review not required

PSGIn‑lab PSG - Covered when criteria met

ActigraphyActigraphy - Not covered

PAP‑NapAbbreviated daytime studies (PAP‑Nap) - Not covered

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Coverage Summary

This policy covers clinical review criteria for sleep studies including attended in‑lab polysomnography (PSG), home sleep apnea testing (HSAT/HST), daytime tests (MSLT/MWT), titration studies, abbreviated daytime studies (PAP‑Nap) and actigraphy for Kaiser Foundation Health Plan of Washington members. The scope governs medical necessity and coverage determinations and distinguishes Medicare and non‑Medicare guidance where noted.

Sleep disorders such as Obstructive Sleep Apnea (OSA) can cause significant morbidity (hypertension, heart disease, stroke, metabolic effects). HSAT is preferred for diagnosing OSA in most adults and, when indicated, does not require medical necessity review; in‑lab PSG is an attended, multi‑parameter study reserved for specific clinical situations.

Policy dates and status

Policy statusMODIFIED

Effective date2024-09-01

Last review date2026-02-03

Material changeyes

Medical Necessity Criteria

Home Sleep Apnea Testing (HSAT) - Non‑Medicare Members

Home Sleep Apnea Testing is preferred and does not require medical necessity review when indicated for adults with suspected OSA.

ALL of the following

HSAT using a portable monitor is medically necessary for evaluating adults with suspected Obstructive Sleep Apnea (OSA).
Where HSAT is indicated, an auto titrating Positive Airway Pressure (APAP) device is an option to determine a fixed PAP pressure.

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Coding

Covered - In‑lab Polysomnography (when criteria met)CPTCovered

95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist.
95808	Polysomnography; Any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist.
95810	Polysomnography; Age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95811	Polysomnography; Age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist.

Covered - Home Sleep Study (medical necessity review not required)mixedCovered

95800	Sleep study, unattended simultaneous recording heart rate, oxygen saturation, respiratory analysis, and sleep time.
95801	Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation and respiratory analysis.
95806	Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort.
G0398	Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation.
G0399	Home sleep study with type III portable monitor, unattended; minimum of 4 channels.
G0400	Home sleep study with type IV portable monitor, unattended; minimum of 3 channels.

Covered - MSLT / MWT (medical necessity review not required)CPTCovered

95805

Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation.

Not Medically Necessary - ActigraphyCPTNot Covered

95803

Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording).

Not Medically Necessary - Abbreviated Daytime Sleep Studies (e.g., PAP‑Nap)CPTNot Covered

unspecified

Abbreviated daytime sleep studies (e.g., PAP‑Nap) - considered not medically necessary (no specific CPT listed).

Provider Actions & Billing

Prior Authorization

Pre-authorization check

Verify authorization requirements for specific codes by plan type using the Pre-authorization Code Check; some codes may require authorization.

Documentation Required

Clinical documentation required for medical necessity review

When requesting these services, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Submit last 6 months of clinical notes from requesting provider/specialist

Background

Home Sleep Apnea Testing (HSAT) is the preferred initial diagnostic approach for adults with suspected OSA because it provides unattended portable monitoring of respiration, heart rate and oxygenation in the home setting and is sufficient for most typical presentations of OSA; HSAT codes do not require medical necessity review when used as indicated.

Attended full‑channel polysomnography (PSG) in a laboratory is reserved when HSAT is inappropriate, inconclusive, or when specific clinical features are present — examples include children/adolescents (<18 years), negative/indeterminate/technically inadequate HSAT with continued clinical suspicion, suspected central sleep apnea prior to hypoglossal nerve stimulator (HGNS) implantation or calibration, suspected sleep seizures (with seizure montage), PLMD/RLS not responsive to empiric treatment, rapid eye movement sleep behavior disorder (RBD), and situations requiring complex titration such as BiPAP settings in moderate‑to‑severe heart failure or when APAP trials are not appropriate (e.g., overt sleep‑related hypoxia requiring oxygen titration).

Certain tests are considered not medically necessary due to insufficient evidence — actigraphy for evaluation of sleep disorders and abbreviated daytime studies (PAP‑Nap) — while daytime tests for narcolepsy/hypersomnia (MSLT) and wakefulness assessment (MWT) have defined indications and are covered when criteria are met.

Definitions

HSAT / HSTHome Sleep Apnea Testing: unattended portable monitor testing to evaluate for obstructive sleep apnea.

PSGPolysomnography: attended full‑channel sleep study performed in a healthcare facility or laboratory setting.

Medicare Determinations

Type	Number	Name
NCD	240.4.1	Sleep Testing for Obstructive Sleep Apnea (OSA)
LCD	L36861	Polysomnography and Other Sleep Studies
LCA	A57697	Billing and Coding: Polysomnography and Other Sleep Studies
LCA	A55478	Billing and coding: Abbreviated Daytime Sleep Study (e.g., PAP‑NAP)

Revision History

2024-09-01added

MPC approved to adopt criteria for Sleep Studies; merged Actigraphy criteria with Sleep Studies criteria; requires 60-day notice.

2026-07-01revisedLatest

MPC approved proposed criteria update to in‑center sleep studies, updating in‑lab PSG/titration indications including HGNS and heart failure titration; requires 60-day notice.

Policy Summary

PayerKaiser Permanente

PolicySleep_Studies

Policy CodePolicy N/A

Change TypeMaterial revisions to in‑lab PSG/titrationmerged actigraphy criteria

Effective DateSep 1, 2024

Next Review Date

Key ActionWhen requesting these services, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

On This Page

Diagnostic Attended Full-Channel Polysomnography (PSG) - In‑lab

Attended full-channel PSG may be considered medically necessary for evaluating individuals with suspected OSA when ANY of the following are met (non‑Medicare guidance used when Medicare guidance absent).

ANY of the following

Individual is a child or adolescent (i.e., less than 18 years of age).
Results of previous HSAT are negative, indeterminate, or technically inadequate to make a diagnosis of OSA and Obstructive Sleep Apnea remains clinically suspected.
To rule out Central Sleep Apnea prior to implantation and/or calibration of an implantable hypoglossal nerve stimulator (for confirmed OSA).
Refer to Sleep Apnea Treatments policy for HGNS indications.
Individual is suspected to have sleep seizures and seizure montage is being requested concurrently with polysomnography.
Periodic Limb Movement Disorder (PLMD) / Restless Legs Syndrome (RLS)/Willis-Ekbom Disease not responsive to empiric treatment (and not leg movements associated with another disorder).
Rapid Eye Movement Sleep Behavior Disorder (RBD).
Central Sleep Apnea is suspected.

Titration Attended Full-Channel Polysomnography (PSG) - In‑lab

Attended PSG for PAP titration may be considered medically necessary if diagnostic PSG criteria above are met AND one of the titration-specific conditions is met.

ALL of the following

Criteria for diagnostic PSG enumerated above have been met.
AND one of
- A split-night sleep study for diagnosis and PAP titration.
- A full night study for PAP titration when the patient failed APAP trial, or a split-night study is inadequate or not feasible and the individual has a confirmed diagnosis of OSA.

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PAP Titration Exceptions

Attended PSG for PAP titration may be considered medically necessary when diagnosis of sleep apnea is present and ANY of the following apply:

ANY of the following

Results of previous HSAT or in-lab PSG are positive for OSA or Central Sleep Apnea and patient symptoms persist despite adequate PAP trial and common issues (equipment failure, improper mask fit, pressure leaks, unsuccessful titration, inadequate pressure, and medical problems including nasal congestion) have been addressed and managed.
Individual has moderate to severe heart failure (NYHA class III or IV or LVEF ≤ 40) and a titration study is needed for BiPAP settings.
Presence of conditions for which APAP trial would not be appropriate (e.g., overt sleep-related hypoxia requiring O2 titration).

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Hypoglossal Nerve Stimulator (HGNS) Device Titration

In‑lab PSG may be considered medically necessary for HGNS up‑titration when ONE of the following criteria is met:

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Daytime Sleep Studies - MSLT and MWT

Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT) medical necessity criteria:

ALL of the following

ALL of the following
- Suspected Narcolepsy or idiopathic Hypersomnia.
- Other causes of Excessive Sleepiness have been excluded by appropriate clinical assessment.
ANY of the following
- An adult who is unable to stay awake, resulting in a safety issue.
- Assessing response to treatment in adults with sleep disorders.

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Abbreviated Daytime Sleep Studies (e.g., PAP‑Nap)

Coverage determination:

ALL of the following

Abbreviated daytime sleep studies (e.g., PAP‑Nap) are considered not medically necessary due to insufficient evidence of efficacy.

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Actigraphy Testing

Coverage determination:

ALL of the following

Actigraphy testing for the evaluation of sleep disorders is considered not medically necessary due to insufficient evidence that it is as safe and/or provides better long‑term outcomes than standard services.

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Billing Rule

Home Sleep Testing - medical necessity review not required

Home sleep study CPT/HCPCS codes (95800, 95801, 95806, G0398, G0399, G0400) do not require medical necessity review when used for HSAT as indicated.

Affected codes: 95800, 95801, 95806, G0398, G0399, G0400

Denial Risk

Actigraphy and abbreviated daytime studies are not covered

Claims for actigraphy (95803) and abbreviated daytime sleep studies (e.g., PAP‑Nap) are considered not medically necessary and may be denied.

Affected codes: 95803 and abbreviated daytime studies (PAP‑Nap)

HGNSHypoglossal Nerve Stimulator used for treatment of OSA; PSG may be used for device titration.