Polysomnography & Sleep Studies
This document governs reimbursement, coding, and documentation requirements for polysomnography and other sleep studies for Priority Health members (commercial, Medicare per CMS, and Medicaid per MDHHS). It affects providers submitting claims for sleep testing and related services.
Added CPT codes 95810 and 95811 guidance regarding billing for the same night.
Set limits for CPT 95803 actigraphy repeat testing: do not report more than once in any 14-day period and not in conjunction with 95806-95811.
Defined limits on number of polysomnography sessions reimbursed for diagnosis or treatment modification in a 12-month period.
Coverage Criteria for Sleep Studies
Coverage criteria
Coverage is conditional on medical necessity, appropriate setting, documentation, and frequency limits.
ALL of the following
Polysomnography frequency
- Reimburse up to two polysomnography sessions for diagnosis of sleep disorders or modifications to a treatment plan during any 12-month period.
- Polysomnography used to titrate CPAP therapy is payable for a single session; routine use of polysomnography for CPAP titration is not separately payable.
Home sleep study frequency
- One home sleep study is payable per 12-month period; additional home sessions require supporting documentation of medical necessity.
Sleep nap and MSLT
- Up to 3 sleep nap sessions will be reimbursed when diagnosing narcolepsy as the standard to confirm this diagnosis.
- Multiple sleep latency studies inherently include multiple sessions and should be coded as a single unit.
CPT/HCPCS Codes, Frequencies, and Billing Rules
| 95782 | Sleep staging (EEG) or related |
| 95783 | Related sleep monitoring |
| 95800 | Sleep study, unattended home sleep study |
| 95801 | Sleep study, attended (polysomnography) or similar home device |
| 95803 | Actigraphy testing (wrist activity monitoring) |
| 95805 | Multiple sleep latency or nap study |
| 95806 | Polysomnography with initiation of CPAP |
| 95807 | Polysomnography with titration |
| 95808 | Polysomnography (other) |
| 95810 | Polysomnography; diagnostic |
Provider Requirements, Authorization, and Modifier Use
Pre‑service organization determination (PSOD) and authorization
For Medicare members, complete a Pre‑Service Organization Determination (PSOD) when indications do not meet an NCD, local LCD, or specific medical policy. Authorization may also be required for services furnished in the appropriate setting; consult the Provider Manual for PSOD and authorization procedures.
- PSOD required when indications do not meet NCD, LCD, or specific medical policy.
- Authorization may be required for services based on place of service and medical need; see Provider Manual.
Modifier application per CMS NCCI and Provider Manual
Apply modifiers consistent with CMS NCCI guidance and Priority Health billing rules; modifiers must be supported by documentation. Incorrect modifier application may result in claim denials—refer to the Provider Manual for detailed modifier use.
- Use Modifier 52 (Reduced services) when applicable and documented.
- Ensure documentation justifies the modifier; improper use can lead to denial or recoupment.
Key Definitions
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