ModifiedUnitedHealthcarePolicy CS098ID.D

Sleep Studies (for Idaho Only)

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Medical policy governing coverage and medical necessity criteria for home and attended sleep studies and related daytime tests for UnitedHealthcare Community Plan members in Idaho, including Idaho Medicaid Plus.

Policy Summary

PayerUnitedHealthcare

PolicySleep Studies (for Idaho Only)

Policy CodePolicy CS098ID.D

Change TypeCoverage criteria reviseddefinitions updated

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionObtain and document indications per updated policy before scheduling attended polysomnography or PAP titration; HSAT should be used first for adults with suspected OSA when appropriate.

SourceLink

POLICY UPDATE CHANGES

Replaced criterion requiring prior HSAT results to exclude 'technically inadequate' — now requires previous HSAT (within 12 months) to be negative or indeterminate to make a diagnosis of OSA.

Clarified parasomnia/RBD indication language to include 'behaviors' and broadened wording for behaviors suspicious of RBD.

Expanded PAP titration indication to allow a full-night PAP titration when the individual has a confirmed diagnosis of OSA or other sleep‑disordered breathing (previously required confirmed OSA).

Clarified that repeat attended PSG and repeat PAP titration are medically necessary in listed circumstances when the criteria for an attended study are met; removed cardiovascular disease change as a repeat-testing trigger and limited weight-change trigger to ≥ 10%.

Updated definition of 'Polysomnography (Attended)' and added instruction to refer providers to the Idaho Medicaid Provider Handbook for non-covered and excluded services.

Idaho onlyGeographic

HSAT permittedHSAT stance

HSAT negative/indeterminate within 12mPSG trigger

≥10% weight changeRepeat testing

24 studiesRoeder review

CS098ID.CPrior version

Coverage and Medical Necessity Criteria

Home Sleep Apnea Testing (HSAT) - Adults with suspected OSA

Covered when ALL of the following are met:

HSAT initial indication: HSAT using a portable monitor is medically necessary for evaluating adults with suspected obstructive sleep apnea (OSA).

Where HSAT is indicated, an Autotitrating Positive Airway Pressure (APAP) device may be used to determine a fixed PAP pressure.

Attended full-channel Polysomnography for suspected OSA

Attended PSG is medically necessary when ANY of the following are met:

Indication A: Results of previous (within the past 12 months) HSAT are negative or indeterminate to make a diagnosis of OSA.within the past 12 months

Indication B - Comorbidities prohibiting HSAT: Individual has one or more comorbid conditions prohibiting the use of a HSAT: significant chronic pulmonary disease (FEV1% predicted < 60%), progressive neuromuscular/neurodegenerative disease, moderate to severe heart failure (NYHA class III or IV) or left ventricular ejection fraction ≤ 40%, or BMI ≥ 50.FEV1% <60%; NYHA III/IV or LVEF ≤40%; BMI ≥50

Examples of neuromuscular disease include Parkinson's disease, myotonic dystrophy, ALS, MS with pulmonary disease, prior stroke with persistent neurological sequelae.

Attended PSG for other conditions

Attended PSG is medically necessary following clinical assessment for:

PLMD: Periodic Limb Movement Disorder (not leg movements associated with another disorder such as sleep-disordered breathing).

RLS: Restless Legs Syndrome/Willis-Ekbom Disease that has not responded to treatment.

Parasomnia with documented disruptive, violent, or potentially injurious sleep behaviors or behaviors suspicious for Rapid Eye Movement Sleep Behavior Disorder (RBD).

Occurs when OSA has been excluded or adequately treated as clinically appropriate.

Narcolepsy once other causes of excessive sleepiness have been ruled out by appropriate clinical assessment (see Daytime Sleep Studies for MSLT/MWT criteria).

Central Sleep Apnea identified on clinical assessment requiring in-laboratory attended study for diagnosis and characterization.

Attended PAP titration

When the criteria for attended PSG are met, the following are medically necessary:

Split-night study: A split-night sleep study performed in a healthcare facility or laboratory setting for diagnosis and PAP titration is medically necessary.

Full-night PAP titration: A full-night study for PAP titration when the individual has a confirmed diagnosis of OSA or other sleep-disordered breathing.

Applies when criteria for attended full-channel polysomnography are met.

Repeat attended testing

Repeat attended PSG and PAP titration are medically necessary when ANY of the following are present:

Persistent symptoms: Persistent, recurrent, or new symptoms despite documented appropriate current treatment or PAP therapy after addressing common issues (e.g., equipment failure, improper mask fit, pressure leaks, unsuccessful titration, inadequate pressure, nasal congestion).

Document that common reversible causes have been evaluated and managed prior to repeat testing.

Weight change: Clinically significant weight loss or gain since the last study.≥ 10%

Clinically significant weight change is defined as ≥ 10% change since the prior study.

Daytime sleep studies

MSLT and MWT coverage:

MSLT: Multiple Sleep Latency Testing is medically necessary for evaluating suspected narcolepsy or idiopathic hypersomnia when other causes of excessive sleepiness have been excluded by appropriate clinical assessment.

Refer to InterQual CP: Procedures: Sleep Studies for detailed clinical coverage criteria.

MWT: Maintenance of Wakefulness Testing is medically necessary for assessing an adult who is unable to stay awake resulting in a safety issue, or for assessing response to treatment in adults with sleep disorders.

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

Diagnosis and device selection

Diagnostic criteria and device selection described in policy text

Diagnostic thresholds: Diagnosis of OSA is confirmed on PSG if obstructive events are > 15 events/hour in the absence of associated symptoms, or ≥ 5 events/hour in an individual with associated symptoms (unintentional sleep episodes, daytime sleepiness, unrefreshing sleep, fatigue, insomnia, waking gasping/choking, or partner report of loud snoring/breathing interruptions).AHI/RDI >15 or ≥5 with symptoms

AASM diagnostic thresholds cited.

Device selection: PSG (in-lab, attended) is used when indicated; HSAT (unattended home testing) records breathing rate, airflow, heart rate, and oxygen and may be used to diagnose OSA in appropriate individuals. Device classification (Type 1–4) guides selection: Type 1 = full attended PSG (≥7 channels), Type 2 = full unattended PSG (≥7 channels), Type 3 = limited channel devices (4–7 channels), Type 4 = 1–2 channels typically including oximetry.Type 1–4 device definitions

AASM/Collop classifications referenced.

Number of nights and repeat testing

Evidence and operational notes on number of nights

Single-night HSAT acceptable for many individuals: Single-night HSAT can correctly diagnose OSA in the majority of individuals with high pretest probability; night-to-night variability exists and may change severity classification in some individuals.

Systematic review (Roeder et al.) found on average 41% of participants showed >10/hour change and 49% changed severity class; reported HSAT data loss ranges ~3–33%.

Repeat testing indications: If HSAT is normal in a high-risk individual or technically inadequate (data loss), in-lab PSG is recommended; technical failure rates for unattended monitoring vary and a second night may be warranted if device failure occurs.

AASM notes insufficient evidence to support routine multiple-night HSAT; repeat HSAT after a single negative/inconclusive/technically inadequate test is discouraged and PSG is recommended.

Treatment and titration pathways

Comparative effectiveness evidence on ambulatory vs in-lab pathways

Home-based diagnostic and treatment pathway: For individuals with high pretest probability of OSA, ambulatory management using portable-monitor testing and unattended APAP titration yields similar functional outcomes and CPAP adherence compared to in-laboratory PSG and titration.

Supported by randomized trials and systematic reviews (Kuna 2011; McArdle 2010; Lettieri 2011; Berry 2008).

Split-night vs dual-night titration: Split-night PSG (diagnosis plus titration in one night) is an accepted approach and has not been shown to adversely affect short-term CPAP adherence compared to dual-night approaches.

AASM suggests split-night protocol when clinically appropriate.

Attended PSG, PAP Titration, and Repeat Testing (summary of revisions)

Attended full-channel polysomnography and PAP titration coverage updated:

Attended PSG for suspected OSA: Revised: previous HSAT within 12 months must have results that are negative or indeterminate to make a diagnosis of OSA (previous wording included 'technically inadequate').within the past 12 months

Providers must use the updated HSAT-result language when determining medical necessity for an attended PSG.

Attended PAP titration: Revised: a full-night study for PAP titration is medically necessary when the individual has a confirmed diagnosis of OSA or other sleep-disordered breathing (expanded from prior wording).

Applies when criteria for attended full-channel polysomnography are met.

Repeat attended PSG and PAP titration: Revised: Repeat attended full-channel PSG and repeat PAP titration are medically necessary in listed circumstances when the criteria for an attended study are met.

Language clarified to explicitly tie repeat testing to attended-study criteria.

Repeat testing after weight change: Repeat testing is medically necessary for individuals who have experienced a clinically significant weight loss or gain since the last study.>= 10%

Changed to retain weight-change trigger (≥ 10%) and removed the prior cardiovascular disease change criterion.

Attended Polysomnography, PAP Titration, and Repeat Testing (revised)

Policy updated coverage criteria and indications for attended polysomnography, PAP titration, and repeat testing.

HSAT prior result requirement: Previous (within the past 12 months) HSAT results must be negative or indeterminate to make a diagnosis of OSA for consideration of attended full-channel polysomnography.within the past 12 months

Replaced prior language that also included 'technically inadequate'.

Parasomnia/RBD indication: Parasomnia with documented disruptive, violent, or potentially injurious sleep behaviors or behaviors suspicious of Rapid Eye Movement Sleep Behavior Disorder (RBD) may be an indication for attended polysomnography following appropriate clinical assessment when OSA has been excluded or adequately treated.

Wording clarified to include 'behaviors' and RBD suspicion.

PAP titration indication: A full-night study for PAP titration is medically necessary when the individual has a confirmed diagnosis of OSA or other sleep-disordered breathing and a split-night study is inadequate or not feasible.

Expanded from prior requirement that diagnosis be OSA only.

Repeat testing: Repeat attended full-channel polysomnography and repeat PAP titration are medically necessary in listed circumstances when criteria for an attended study are met; clinically significant weight change (≥ 10% since last study) is one listed circumstance.>= 10%

Removed prior mention of changes in cardiovascular disease as a trigger.

Attended full‑channel polysomnography is considered not medically necessary for the evaluation of circadian rhythm disorders, depression, or insomnia. The policy also states that actigraphy is not medically necessary for any sleep disorders when proposed as a replacement for attended PSG in these indications.

Abbreviated daytime sleep studies (for example, PAP‑Nap tests) are not medically necessary because current evidence is insufficient to establish their efficacy. The policy references pilot data for these abbreviated daytime procedures but states larger prospective studies are needed to support routine use.

The evidence base for actigraphy is limited and does not support using actigraphy as a stand‑alone diagnostic test for sleep disorders. Systematic reviews and evidence assessments cite small, heterogeneous studies with inconsistent results and insufficient quality to validate actigraphy as an alternative to conventional sleep studies.

Routine performance of more than a single night of Home Sleep Apnea Testing (HSAT) is not supported by current evidence. AASM concluded that a single‑night HSAT is adequate for many appropriate patients and that evidence is insufficient to establish superiority of multi‑night protocols. When an initial HSAT is negative, inconclusive, or technically inadequate, the guidance is to proceed to an attended PSG rather than perform a repeat HSAT.

For information on additional non‑covered and excluded services beyond those listed in this policy, refer providers to the Idaho Medicaid Provider Handbook, General Information: Non‑Covered and Excluded Services.

Summary: Actigraphy and attended PSG are not medically necessary in certain scenarios. Specifically, attended PSG is not indicated for circadian rhythm disorders, depression, or insomnia, and actigraphy lacks sufficient evidence to function as a sole diagnostic modality for sleep disorders.

The policy indicates that the use of actigraphy as a stand‑alone test is not supported for conditions including narcolepsy, insomnia, obstructive sleep apnea (OSA), or periodic limb movement disorder (PLMS) because published studies are limited in number, heterogeneous, and do not establish diagnostic accuracy or impact on clinical outcomes.

The American Academy of Sleep Medicine (AASM) guidance cited in the policy includes a clear recommendation that clinicians should not use actigraphy in place of electromyography (EMG) for the diagnosis of periodic limb movement disorder in adults. This is reported as a strong recommendation in the AASM guideline.

This policy segment does not list a comprehensive set of specific conditions deemed not medically necessary; providers should consult the full policy and the Idaho Medicaid Provider Handbook for additional non‑covered or excluded services.

Coding and Key Clinical Thresholds

Applicable CPT CodesCPT

95800	Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time.
95801	Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone).
95803	Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording).
95805	Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness.
95806	Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement).
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 bilevel ventilation, attended.

Applicable HCPCS CodesHCPCS

G0398	Home sleep study test (HST) 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 test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation.
G0400	Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.

Referenced CPT codesCPT

CPT 95807-52

Daytime, abbreviated cardio-respiratory sleep study (referenced in Krakow PAP-Nap pilot)

FDA product codes (informational)mixed

product code OLV	FDA product code for systems to record and analyze PSG information (informational)
product code MNR	FDA product code for HSAT devices (informational)

inv-25: Timeframe for prior HSAT — within the past 12 months

Timeframe for prior HSATResults of previous HSAT must be from within the past 12 months

ContextApplies when considering attended full-channel polysomnography for suspected OSA

Source guidanceKapur et al., 2017 and CMS referenced in policy language

inv-26: Clinically significant weight change — ≥ 10% weight loss or gain

Clinically significant weight change thresholdClinically significant weight loss or gain defined as ≥ 10% since the last study

Repeat testing indicationTriggers repeat attended PSG or PAP titration when this weight-change threshold is met

Revision notePolicy removed cardiovascular disease change; retained ≥ 10% weight-change only

inv-27: Minimum HSAT recording duration — ≥ 4 hours

Minimum HSAT recording durationAdequate HSAT occurs over a minimum of 4 hours

Required sensors (summary)Includes at minimum nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry

TerminologyHSAT may be called out-of-center sleep testing or portable monitoring

inv-28: Obesity Hypoventilation Syndrome BMI — BMI ≥ 30 kg/m2

OHS BMI thresholdObesity Hypoventilation Syndrome defined with BMI ≥ 30 kg/m2

Additional OHS criterionDaytime hypercapnia defined as arterial PaCO2 ≥ 45 mmHg is part of OHS definition

AttributionNot entirely attributable to underlying cardiopulmonary or neurologic disease

inv-29: OSA severity (AHI or RDI) — Mild/Moderate/Severe cutpoints

Mild OSAAHI or RDI ≥ 5 and < 15 events/hour

Moderate OSAAHI or RDI ≥ 15 and ≤ 30 events/hour

Severe OSAAHI or RDI > 30 events/hour

inv-30: Clinically significant weight change (repeat testing threshold) — ≥ 10%

Repeat testing weight-change thresholdRepeat attended PSG/PAP titration permitted when individual has had ≥ 10% weight change since last study

ContextApplies when criteria for an attended study are met and symptoms/persistence warrant repeat testing

ReferencesCaples et al., 2021; Peppard et al., 2000 cited in policy

inv-31: Clinically significant weight change (alternate entry) — >= 10%

Alternate phrasing of weight-change threshold>= 10% weight loss or gain since last study (policy text uses ≥ 10% elsewhere)

Use in policyListed as a circumstance permitting repeat attended PSG or PAP titration when attended-study criteria are met

Revision noteCardiovascular disease change removed from repeat-testing triggers; weight-change retained

Provider Requirements and Operational Notes

Prior Authorization

Medical necessity required for attended studies

Attended full‑channel polysomnography and daytime tests (MSLT, MWT) are medically necessary only when the policy's clinical criteria are met; obtain and document indications per policy before scheduling an attended study.

Billing Rule

Codes referenced (may require authorization)

The policy lists applicable CPT and HCPCS procedure codes for sleep studies and HSAT for reference; inclusion of a code does not guarantee coverage and codes may be subject to benefit rules or prior authorization per contract.

CPT examples: 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811
HCPCS examples: G0398, G0399, G0400

Prior Authorization

Prior authorization requirements for attended polysomnography

Follow the updated policy criteria when requesting prior authorization for attended full‑channel polysomnography and related procedures; submit documentation showing the applicable clinical indications in the policy.

Note

Check Idaho Medicaid handbook for coverage/prior auth details

Refer to the Idaho Medicaid Provider Handbook (General Information: Non‑Covered and Excluded Services) for additional prior authorization, non‑covered, and exclusion details that may affect coverage decisions.

Step Therapy

HSAT before attended PSG when appropriate

Use HSAT as the initial diagnostic option for adults with suspected OSA when appropriate; if a prior HSAT within 12 months is negative or indeterminate, or if comorbid conditions prohibit HSAT, an attended PSG is required.

Policy: HSAT is medically necessary for adults with suspected OSA; APAP may be used when HSAT is indicated.
Attended PSG indicated when prior (within 12 months) HSAT results are negative or indeterminate or when comorbid conditions prohibit HSAT.

Step Therapy

Therapeutic titration pathway

After an OSA diagnosis, perform PAP titration or trial (split‑night PSG or a full‑night PAP titration, or APAP titration at home when appropriate) to determine therapeutic pressure per the policy's pathways.

Split‑night PSG for diagnosis and PAP titration is medically necessary when criteria for attended PSG are met.
A full‑night PAP titration is medically necessary when the individual has a confirmed diagnosis of OSA or other sleep‑disordered breathing.

Denial Risk

Follow-up testing guidance

Do not routinely order follow‑up PSG or HSAT for asymptomatic patients on PAP therapy; reserve follow‑up testing for recurrent or persistent symptoms, assessment after significant weight change, evaluation of unexplained device data, or other scenarios listed in AASM guidance.

Follow‑up testing is recommended for recurrent/persistent symptoms despite good PAP adherence, to assess response to non‑PAP interventions, or after clinically significant weight gain/loss.
Routine reassessment of asymptomatic patients on PAP therapy with PSG/HSAT is not recommended.

Note

No specific provider action

No provider action specified in this document segment.

Documentation Required

Medical record documentation

Ensure the patient's medical record contains history, physical exam findings, and pertinent diagnostic test results that fully support medical necessity; records must be legible and available upon request.

Include relevant medical history, physical examination, and results of prior HSAT or PSG as applicable.

Documentation Required

Study type documentation

Document the diagnosis and clearly indicate the testing location and type (attended in‑lab PSG versus unattended HSAT) to support appropriate test selection and prior authorization requests.

PSG = attended in‑laboratory study with technologist present; HSAT = unattended home testing.

Note

Refer to Idaho Medicaid Provider Handbook

Refer providers to the Idaho Medicaid Provider Handbook for details on non‑covered and excluded services that may affect claims and prior authorization determinations.

Note

Policy scope note

Use this policy as informational guidance but confirm coverage decisions against applicable federal, state, or contractual benefit plan requirements, which govern in the event of conflict.

Denial Risk

Repeat HSAT discouraged

Do not perform a repeat HSAT after a single negative, inconclusive, or technically inadequate HSAT; obtain an attended full‑channel PSG instead, as repeat HSAT is discouraged and may be denied.

AASM and policy state repeat HSAT is not recommended; PSG is strongly recommended after a single inadequate/negative HSAT.

Billing Rule

Coding inclusion disclaimer

Listing a CPT/HCPCS code in this policy is for reference only and does not imply the service described by the code is covered or reimbursable; benefits and applicable laws determine coverage and payment.

Denial Risk

Repeat HSAT not recommended (alternate)

Performing a repeat HSAT in lieu of obtaining an attended PSG after a single negative, inconclusive, or technically inadequate HSAT is not recommended and may lead to denial if the PSG is the indicated next step.

Note

Refer to Idaho Medicaid Provider Handbook for non-covered/excluded services

For additional specifics on non‑covered and excluded services that could affect authorization or claims, consult the Idaho Medicaid Provider Handbook referenced in the policy.

Background and Evidence Summary

Background: Obstructive sleep apnea (OSA) is commonly evaluated using either Home Sleep Apnea Testing (HSAT) or attended full‑channel polysomnography (PSG). HSAT is appropriate as the initial diagnostic approach for many adults with suspected OSA, but attended in‑lab PSG is indicated when HSAT is negative or indeterminate within the prior 12 months or when comorbid conditions prevent reliable HSAT performance. Clinical guidelines note that HSAT adequacy requires a minimum recording duration (commonly ≥ 4 hours) and that PSG remains the reference standard when HSAT is not suitable or when additional diagnostic detail is required.

Definitions

inv-49: Home Sleep Apnea Testing (HSAT) — Unattended diagnostic studies; adequate HSAT ≥4 hours; required channels

HSAT definitionUnattended diagnostic studies to assess for OSA without sleep staging; may be out-of-center or portable monitoring

Adequate HSAT durationAdequate HSAT recording is defined as ≥ 4 hours of monitoring

Required channels for HSATMinimum sensors include nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry (type 3/4 device channel expectations summarized)

inv-50: Apnea / Hypopnea / AHI definitions

Apnea definitionApnea: cessation of airflow ≥90% decrease from baseline lasting at least 10 seconds

Hypopnea definitionHypopnea: ≥30% reduction in airflow for ≥10 seconds with ≥3% oxygen desaturation or associated arousal

AHI calculationAHI = (number of apneas + hypopneas) × 60 / total sleep time (events per hour)

inv-51: OSA severity levels (Mild/Moderate/Severe)

MildAHI or RDI ≥ 5 and < 15 events/hour

ModerateAHI or RDI ≥ 15 and ≤ 30 events/hour

SevereAHI or RDI > 30 events/hour

inv-52: Obesity Hypoventilation Syndrome (OHS) — BMI threshold and hypercapnia definition

OHS definitionObesity Hypoventilation Syndrome: obesity with BMI ≥ 30 kg/m2 plus daytime hypercapnia (PaCO2 ≥ 45 mmHg)

Exclusion clauseHypercapnia not fully attributable to cardiopulmonary or neurologic disease

Clinical consequenceLeads to hypoxemia and hypercapnia due to hypoventilation

inv-53: Obstructive Sleep Apnea (OSA) — general definition

OSA general definitionSleep-related breathing disorder with decreased or halted airflow despite ongoing respiratory effort

Severity criteriaSeverity defined by AHI/RDI thresholds: mild ≥5–<15, moderate ≥15–≤30, severe >30 events/hour

Diagnostic standardPSG is the standard diagnostic test when concerns exist on comprehensive evaluation

inv-54: Respiratory Event Index (REI) — HSAT surrogate metric

REI definitionREI = total respiratory events during entire sleeping period × 60 / monitoring time in minutes

UseREI is used for HSAT as a surrogate for AHI when sleep time is not measured

UnitReported as events per hour

inv-55: Polysomnography (Attended) — laboratory-based multi-channel sleep study definition

Polysomnography (Attended) definitionLaboratory-based sleep study using multiple channels to record brain activity, eye movements, body movements, breathing and heart rate, attended by a technologist

SettingPerformed in a healthcare facility or accredited sleep laboratory

Device complexityFull-channel PSG typically ≥7 channels (Type 1 device)

inv-56: Actigraphy — wearable accelerometer monitoring and limitations

Actigraphy descriptionWearable accelerometer-based monitoring (typically wrist-worn) to estimate sleep and wake based on activity levels

Recommended usesAASM suggests use for insomnia and circadian rhythm assessments and to estimate total sleep time in some HSAT contexts

LimitationsNot a replacement for electromyography in diagnosing PLMD; evidence insufficient to use as a stand-alone diagnostic for many disorders

inv-57: PAP-Nap — abbreviated daytime PAP desensitization/test

PAP-Nap descriptionDaytime abbreviated procedure combining mask/pressure desensitization and psychological techniques delivered during a nap period to improve PAP acceptance

Evidence statusPilot and retrospective studies exist but larger prospective randomized trials are needed to establish clinical value

Typical durationExample protocol includes a ~100-minute nap exposure (Krakow et al., 2008)

inv-58: MSLT / MWT — indications for narcolepsy and hypersomnolence evaluation

MSLT indicationMSLT is indicated for evaluation of suspected narcolepsy or idiopathic hypersomnia when other causes of excessive sleepiness have been excluded

MWT indicationMWT is indicated to assess ability to stay awake when inability to remain awake creates a safety issue or to assess treatment response

Not routine for OSAMSLT/MWT are not routinely indicated in initial OSA evaluation or in assessing change after CPAP

inv-59: Polysomnography (Attended) — definition updated in this policy version

Updated attended PSG definitionPolicy notes an updated definition of 'Polysomnography (Attended)' in this version (exact revised wording in policy)

Policy change contextDefinition update is part of broader revisions to attended PSG, PAP titration, and repeat testing criteria

ReferenceSee Policy History/Revision Information for details (08/01/2026)

Policy Changes and Version History

2026-08-01policy_revisionLatest

Effective 2026-08-01: Revised coverage criteria for attended full-channel polysomnography for suspected OSA — changed prior HSAT result requirement to 'negative or indeterminate' (removed 'technically inadequate'); clarified parasomnia/RBD wording; broadened full-night PAP titration indication to include confirmed OSA or other sleep-disordered breathing; specified repeat attended PSG and repeat PAP titration are medically necessary when attended-study criteria are met; modified repeat-testing weight-change trigger to ≥10% only; updated definition of 'Polysomnography (Attended)'; added referral to Idaho Medicaid Provider Handbook and updated references; archived prior version CS098ID.C.

Policy Summary

PayerUnitedHealthcare

PolicySleep Studies (for Idaho Only)

Policy CodePolicy CS098ID.D

Change TypeCoverage criteria reviseddefinitions updated

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionObtain and document indications per updated policy before scheduling attended polysomnography or PAP titration; HSAT should be used first for adults with suspected OSA when appropriate.

SourceLink

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