CurrentMass General Brigham Health PlanPolicy N/A

sleep_study_and_therapy_management_policy

Defines prior authorization, vendor management (CareCentrix), covered and non‑covered sleep diagnostic studies, PAP/RAD device coverage and supplies, billing requirements, provider responsibilities, and applicable CPT/HCPCS codes for Mass General Brigham Health Plan product lines.

Policy Summary

PayerMass General Brigham Health Plan

Policysleep_study_and_therapy_management_policy

Policy CodePolicy N/A

Change TypeAdministrative updates; annual reviews; code updates

Effective Date

Next Review Date

Key ActionOrdering provider or designee must obtain prior authorization from CareCentrix for all sleep studies, therapy, and supplies and include the authorization number on the claim to avoid denial.

SourceLink

POLICY UPDATE CHANGES

Document restructure; codes, code descriptors and references updated (January 1, 2019).

Clarification for G0399 POS 12 (January 17, 2021).

Document rebrand; updated references (January 1, 2023).

Updated CPT codes (January 1, 2024).

Updated CPT codes (October 31, 2024).

Updated CPT codes and annual review (January 1, 2025).

All sleep studiesPrior Authorization Required

Previously diagnosed OSACPAP coverage limited

First 3 monthsRAD supplies coverage

Actigraphy (95803)

Policy summary

Mass General Brigham Health Plan partners with CareCentrix (CareCentrix iComply) to manage sleep study authorization, vendor selection, therapy initiation, and adherence monitoring. The program centralizes prior authorization and vendor selection so CareCentrix coordinates home sleep tests, in‑network sleep lab scheduling, initiation of PAP therapy when appropriate, and enrollment of PAP recipients into the CareCentrix iComply Therapy Adherence Program to manage utilization and adherence to PAP therapy.

Scope summary: Defines prior authorization, vendor management (CareCentrix), covered and non‑covered sleep diagnostic studies, PAP/RAD device coverage and supplies, billing requirements, provider responsibilities, and applicable CPT/HCPCS codes for Mass General Brigham Health Plan product lines.

Policy Metadata

Policy Titlesleep_study_and_therapy_management_policy

PayerMass General Brigham Health Plan

Effective Date

Last Review2025-01-01

Next Review

Policy StatusCURRENT

Key ActionObtain CareCentrix prior authorization for sleep studies and therapy

Coverage & reimbursement conditions

Coverage / Reimbursement Conditions

Mass General Brigham Health Plan reimbursement rules:

Reimburses home sleep studies as approved by CareCentrix.

Reimburses facility sleep studies as approved by CareCentrix.

Reimburses CPAP only in previously diagnosed OSA patients.

Reimburses RAD and supplies for the first three months of therapy in previously diagnosed patients with one of: Restrictive Thoracic Disorders; Severe COPD; Central Sleep Apnea or Complex Sleep Apnea; Hypoventilation Syndrome.

Does NOT reimburse non-invasive airway devices for any conditions not listed above.

Authorization, vendor selection, and provider responsibilities

Authorization and Vendor Requirements

Services require prior authorization and vendor selection per CareCentrix program:

Prior Authorization required from CareCentrix (CCX) for all sleep studies (home or facility).

Prior Authorization required from CareCentrix (CCX) for sleep therapy, supplies, and vendor selection.

Ordering provider or designee must request and obtain prior authorization; rendering provider must ensure authorization number is present prior to service or claim will be denied.

Site-specific

If requested sleep study can be performed at home, a CCX rendering provider will provide HST, education, interpretation, recommendations, and initiation of PAP therapy when appropriate.

CPT / HCPCS code lists

Prior Authorization Required (CareCentrix)CPT|HCPCS|mixedCovered

94660	Continuous positive airway pressure ventilation (CPAP), initiation and management (note: service not reimbursable when included in CPAP DME service for physician billing)
94799	Unlisted pulmonary service or procedure (Prior Authorization Required from CareCentrix)
95800	Sleep study, unattended; heart rate, oxygen saturation, respiratory analysis, and sleep time (Prior Authorization Required from CareCentrix)
95801	Sleep study, unattended; minimum heart rate, oxygen saturation, and respiratory analysis (Prior Authorization Required from CareCentrix)
95803	Actigraphy testing (Prior Authorization Required from CareCentrix) -- elsewhere listed as not reimbursed
95805	Multiple sleep latency test (Prior Authorization Required from CareCentrix); submit for sleep facility billing; ALWAYS involves at least 4 naps; code once for all naps in a single day
95806	Sleep study, simultaneous recording unattended (Prior Authorization Required from CareCentrix)
95807	Sleep study, simultaneous recording attended by technologist (Prior Authorization Required from CareCentrix); submit for sleep facility billing
95808	Polysomnography; sleep staging with 1-3 additional parameters (Prior Authorization Required from CareCentrix)
95810	Polysomnography; sleep staging with 4 or more additional parameters, attended by technologist

1–10 of 32

1/4

Not Reimbursed / ExclusionsCPTNot Covered

95803	Actigraphy testing, recording, analysis, interpretation, and report (minimum 72 hours to 14 consecutive days) - not reimbursed
95808-95811 when billed with CPT 54250	Polysomnography used to diagnose diseases other than sleep disorders (example: impotence CPT 54250) - not reimbursed

Claims submission and billing requirements

Claims and Billing Requirements

Operational billing rules and provider payment guidelines:

Authorization number must be submitted with the claim to be reimbursed.

Claims for services requiring prior authorization that lack an authorization number will be denied.

Accurate claims payment requires matching billed CPT/HCPCS codes with the authorized services.

Certain codes have specific billing instructions (e.g., 95805: code once for all naps done in a single day for sleep facility billing).

Code-specific billing instructions and prior authorization requirements apply to listed CPT/HCPCS codes (examples include 95805, G0399 Place of Service 12 clarification, and other codes requiring CareCentrix authorization).

Key definitions

Key Definitions

CareCentrix iComply Therapy Adherence ProgramComprehensive member support and monitoring for members prescribed a PAP machine; non-adherent members receive coaching and may be denied continued coverage if non-adherence persists.

Home Sleep Test (HST)Unattended portable monitor sleep test (Type I-IV) performed in the patient's home as approved by CareCentrix.

External determinations

Medicare reference: Medicare National Coverage Determination Manual - Coverage Determinations (as listed in the policy references).

Entry details: Medicare determination entry shown in the brief lists the Medicare National Coverage Determination Manual - Coverage Determinations but does not provide an effective date or number in the brief.

Policy changes and review timeline

2019-01-01revised

Document restructure; codes, code descriptors and references updated (January 1, 2019).

2021-01-17clarified

Clarification for G0399 POS 12 (January 17, 2021).

2023-01-01rebranded

Document rebrand; updated references (January 1, 2023).

Policy Summary

PayerMass General Brigham Health Plan

Policysleep_study_and_therapy_management_policy

Policy CodePolicy N/A

Change TypeAdministrative updates; annual reviews; code updates

Effective Date

Next Review Date

SourceLink

On This Page

Does NOT reimburse sleep studies/polysomnography used to diagnose diseases other than sleep disorders (example: CPT 95808-95811 when billed with CPT 54250).

Does NOT reimburse CPT 95803 (actigraphy testing).

If study is to be performed at a sleep lab, the sleep facility must obtain the authorization number from the referring provider at scheduling.

Members under age 16: facility sleep studies authorized only at Mass General Brigham Health Plan contracted sleep facilities.

Members age 16 and older: authorization may be for contracted sleep facility or home sleep test (HST) per current guidelines/criteria.

Prior Authorization

Obtain CareCentrix prior authorization for sleep studies and therapy

Ordering provider or designee must obtain prior authorization from CareCentrix for all sleep studies, sleep therapy, and supplies; the authorization number must be included on the claim or the claim will be denied.

Documentation Required

Rendering provider must verify authorization prior to service

Rendering (diagnostic, sleep lab, HST and DME) providers are responsible for ensuring required authorization numbers are present prior to performing services; absent authorization numbers will result in claim denial.

Prior Authorization

Individual prior authorizations for supplies and re-supplies

All sleep supplies and re-supplies require individual prior authorizations from CareCentrix; requests may be submitted by phone, fax, or web portal.

Phone: 1-866-827-5861 (M–F 8 AM–6 PM EST)
Fax: 1-866-536-8046 (M–F 8 AM–6 PM EST)
Web portal: HomeBridge CareCentrix Provider Portal / sleep branded portal

Denial Risk

Claims risk if no authorization

Claims for services requiring prior authorization which lack an authorization number will be denied.

Billing Rule

Match billed codes to authorized services

Accurate claims payment requires matching billed CPT/HCPCS codes with the authorized services; specific billing instructions apply for certain codes.

CPT 95805: Code once for all naps done in a single day (submit for sleep facility billing)
Affected codes: [95805]

Billing Rule

Authorization number required on claim

Authorization number must be submitted with the claim to be reimbursed; claims for services requiring prior authorization that lack the authorization number will be denied.

Impacted claim types: sleep studies, sleep therapy (PAP/RAD), and supplies

2024-01-01revised

Updated CPT codes (January 1, 2024). Annual review noted no policy change.

2024-10-31revised

Updated CPT codes (October 31, 2024).

2025-01-01revisedLatest

Updated CPT codes and annual review (January 1, 2025). Annual review, no policy change noted.