CurrentmhnPolicy CP.MP.24

Multiple Sleep Latency Testing

Defines medical necessity criteria and requirements for performing Multiple Sleep Latency Testing (MSLT) for suspected narcolepsy or idiopathic hypersomnia for members/enrollees aged ≥2 years within health plans affiliated with Centene Corporation.

Policy Summary

Payermhn

PolicyMultiple Sleep Latency Testing

Policy CodePolicy CP.MP.24

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for CPT 95805 and document ≥8 weeks of excessive daytime sleepiness with Epworth ≥10 and an overnight PSG without significant sleep pathology.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥2minimum age for medically necessary MSLT

≥8wduration of excessive daytime sleepiness required

Epworth ≥10Epworth Sleepiness Scale threshold

95805referenced CPT code for MSLT

Coverage Criteria for MSLT

inv-01: Initial Therapy / Initial MSLT

Covered when ALL of the following are met

Initial MSLT (ages >= 2): A. Excessive daytime sleepiness (EDS) for ≥ eight weeks, as measured by a score of ≥ 10 on the Epworth Sleepiness Scale;

Pediatric consultation requirement (if age < 11)

B1: Has had a consultation with a pediatric neurologist, pediatric pulmonologist, or pediatric sleep medicine specialist, and the MSLT has been ordered by the consulting physician;
B2: The MSLT will be conducted in a facility specializing in pediatric sleep disturbances with pediatric consultants available;

Policy Summary

Payermhn

PolicyMultiple Sleep Latency Testing

Policy CodePolicy CP.MP.24

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for CPT 95805 and document ≥8 weeks of excessive daytime sleepiness with Epworth ≥10 and an overnight PSG without significant sleep pathology.

SourceLink

On This Page

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inv-02: Continuation Therapy / Repeat MSLT

Repeat MSLT is covered when ALL of section I criteria are met AND at least one of the following

Repeat MSLT

A: The initial test findings are invalid or uninterpretable;
B: The initial test is affected by extraneous circumstances, or appropriate study conditions were not present during initial testing;
C: The member/enrollee is suspected to have narcolepsy, but previous MSLT evaluation did not provide polygraphic confirmation.

MSLT is considered not medically necessary when the pre-test overnight PSG demonstrates significant sleep pathology (e.g., obstructive sleep apnea or central sleep apnea) that could explain excessive sleepiness, or when the policy's required criteria are not satisfied. Required criteria include documented excessive daytime sleepiness for ≥ 8 weeks with an Epworth Sleepiness Scale score ≥ 10, age-appropriate specialty consultation and pediatric facility requirements for children <11 years, exclusion or treatment of medical contributors, medications deemed noncontributory, management of psychiatric disorders, and exclusion of drug or alcohol misuse. If these conditions are not met, MSLT should not be performed for the purposes described in this policy.

Coding, Metrics, and Clinical Thresholds

Referenced 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-06: Mean sleep latency — clinical thresholds (< 8 minutes per ICSD-3 for narcolepsy; <5 minutes distinctly abnormal)

ICSD-3 mean sleep latency thresholdMean sleep latency < 8 minutes is required per ICSD-3 for narcolepsy diagnosis.

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

Pediatric notePrepubertal children may have longer latencies (8–15 minutes may suggest pathologic sleepiness), so thresholds may differ in young children.

inv-07: Epworth Sleepiness Scale — threshold value for policy

Epworth Sleepiness Scale thresholdEpworth Sleepiness Scale score ≥ 10 is required to document excessive daytime sleepiness for policy eligibility.

Role in criteriaUsed as the measure of EDS duration/severity in initial MSLT eligibility (combined with ≥ 8 weeks of symptoms).

Age applicabilityApplies to members aged ≥ 2 years as part of MSLT eligibility criteria.

inv-08: Duration of EDS — required duration for eligibility

Required duration of symptomsExcessive daytime sleepiness (EDS) must be present for ≥ 8 weeks to meet the policy's eligibility requirement for MSLT.

Context with EpworthDuration requirement is combined with an Epworth score ≥ 10 to establish eligibility.

PurposeEnsures persistent rather than transient sleepiness before proceeding with MSLT.

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for CPT 95805 per plan rules. Providers must obtain prior authorization before scheduling MSLT (CPT 95805).

Affected code: CPT 95805 — prior authorization required

Step Therapy

Step therapy: No step therapy is specified for MSLT. There are no required prior conservative treatments or stepwise trials before authorization of CPT 95805 under this policy.

Denial Risk

Triggers for Denial

Triggers that may lead to denial include: significant sleep pathology on the pre-test PSG (for example, untreated moderate-to-severe obstructive sleep apnea or central sleep apnea) which invalidates MSLT results; insufficient documentation of excessive daytime sleepiness (e.g., no Epworth Sleepiness Scale score ≥ 10 for ≥ eight weeks); lack of documentation that medical conditions and medications contributing to sleepiness were considered and managed; absence of required pediatric specialist consultation and pediatric facility setting for patients < 11 years when applicable; and evidence of active substance misuse or unmanaged psychiatric disorder that could confound results.

Significant sleep-disordered breathing or other pathology on prior PSG
Epworth Sleepiness Scale < 10 or EDS duration < 8 weeks
Unmanaged contributing medical conditions or medications
Missing pediatric consultation or pediatric-specialized facility for ages < 11 when required
Active substance misuse or uncontrolled psychiatric disorder

Definitions and Key Terms

inv-14: Mean sleep latency — definition/term entry

DefinitionMean sleep latency is the average time it takes an individual to fall asleep across the multiple nap opportunities during an MSLT.

Measurement contextCalculated from four or five 20-minute nap opportunities conducted at two-hour intervals during the day following an overnight PSG.

Clinical interpretationShorter mean sleep latency indicates greater severity of sleepiness; thresholds in policy reference ICSD-3 and <5 minutes as distinctly abnormal.

inv-15: SOREMP — Sleep onset REM period definition

DefinitionSOREMP (sleep onset REM period) is an occurrence of REM sleep that begins at sleep onset during a nap opportunity on the MSLT.

Diagnostic relevanceTwo or more SOREMPs plus mean sleep latency < 8 minutes are required by ICSD-3 for narcolepsy diagnosis, as referenced in the policy.

DetectionSOREMPs are identified via EEG and other polysomnographic measures recorded during MSLT nap trials.

inv-16: Excessive daytime sleepiness (EDS) — policy definition (>=8 weeks and Epworth >=10)

Policy definition of EDSExcessive daytime sleepiness (EDS) for this policy is defined as symptoms present for ≥ 8 weeks with an Epworth Sleepiness Scale score ≥ 10.

Age applicabilityApplies to members aged ≥ 2 years when combined with other policy criteria for MSLT.

Role in coverage criteriaEDS meeting this definition is a required component of the initial MSLT medical necessity criteria (section I.A).

OpenPayer

Multiple Sleep Latency Testing

Coverage Criteria for MSLT

Coding, Metrics, and Clinical Thresholds

Provider Requirements and Actions

Background

Definitions and Key Terms