CurrentUnitedHealthcarePolicy CS098KS.02

Sleep Studies (for Kansas Only)

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Policy governing clinical coverage criteria and coding for sleep studies for UnitedHealthcare members in Kansas; applies to providers submitting claims or requests for sleep diagnostic testing in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicySleep Studies (for Kansas Only)

Policy CodePolicy CS098KS.02

Change TypeDocumentation and references updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains documentation that fully supports medical necessity, including relevant history, physical exam, and diagnostic test results.

SourceLink

POLICY UPDATE CHANGES

Added medical records documentation requirements clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess whether the member meets clinical criteria.

Specified that the patient's medical record must contain documentation that fully supports medical necessity, including relevant history, physical exam, and diagnostic test results.

Updated References section to reflect current information and archived previous policy version CS098KS.01.

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CurrentUnitedHealthcarePolicy CS098KS.02

Sleep Studies (for Kansas Only)

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Policy Summary

PayerUnitedHealthcare

PolicySleep Studies (for Kansas Only)

Policy CodePolicy CS098KS.02

Change TypeDocumentation and references updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains documentation that fully supports medical necessity, including relevant history, physical exam, and diagnostic test results.

SourceLink

POLICY UPDATE CHANGES

Specified that the patient's medical record must contain documentation that fully supports medical necessity, including relevant history, physical exam, and diagnostic test results.

Updated References section to reflect current information and archived previous policy version CS098KS.01.

Coverage Criteria and Scope

Delegated clinical criteria

Clinical coverage is determined by external criteria sources and state requirements:

Primary criteria sources: Coverage determinations follow the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual and InterQual clinical criteria where applicable.

Providers must reference these sources for specific clinical inclusion/exclusion criteria and to determine prior authorization requirements.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws, which may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment; other policies and guidelines may apply.

This policy does not itself define every scenario that would be considered not medically necessary. Coverage and noncoverage determinations are governed by the referenced state manuals, federal or contractual requirements, and the clinical criteria sources cited elsewhere in this policy; providers should refer to those sources when assessing medical necessity for an individual member.

Procedural and Billing Codes

Covered CPT Codes (pediatric PSG)CPT

95782	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
95783	Polysomnography; younger than 6 years, 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 CPT Codes (adult and general PSG/HST related)CPT

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 by a technologist.

Covered HCPCS Codes (home sleep testing)HCPCS

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.

inv-07: Actigraphy recording duration — CPT 95803

Actigraphy recording duration (CPT 95803)Minimum of 72 hours to 14 consecutive days of recording

Procedure descriptionActigraphy testing includes recording, analysis, interpretation, and report

CodeCPT 95803

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior authorization and criteria source

Medical necessity determinations follow InterQual as the primary criteria source; providers must also check and follow any applicable federal, state, or contractual prior authorization requirements when requesting sleep diagnostic services.

Refer to InterQual® for primary medical/surgical criteria.
Verify federal, state, or contractual prior authorization rules before submitting requests.

Note

Provide complete, legible medical records with requests

When submitting requests or claims, ensure the medical record contains complete, legible documentation that supports the medical necessity of the requested sleep study or test.

Ensure documentation is consistent with InterQual and any state/contractual requirements.
Make records available upon request during review.

Background and Purpose

Polysomnography (PSG) and home sleep testing (HST) are diagnostic modalities used to evaluate sleep disorders such as obstructive sleep apnea. PSG typically refers to attended in-lab studies with sleep staging and physiologic parameter monitoring, while HST refers to unattended portable monitoring using type II–IV devices with specified channel minimums. Clinical coverage for these studies is determined using the state-specific Kansas Medical Assistance Program guidance and InterQual criteria as referenced in this policy, and documentation in the medical record must support the requested service.

Definitions and Test Types

inv-13: Polysomnography (PSG)

General PSG definitionPolysomnography (PSG): sleep staging with additional parameters of sleep, attended by a technologist

Adult PSG (age 6+)CPT 95810: Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters, attended by a technologist

Adult PSG with PAP initiationCPT 95811: Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters, with initiation of CPAP or bilevel ventilation, attended by a technologist

Any-age PSG (fewer additional parameters)CPT 95808: Polysomnography; any age, sleep staging with 1-3 additional parameters, attended by a technologist

Pediatric PSG codesCPT 95782 and 95783 describe PSG for children younger than 6 years (with and without initiation of PAP therapy)

Policy Changes and Revision History

2026-02-01policy_revisionLatest

Added and operationalized medical records documentation requirements clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess whether the member meets clinical criteria; specified required contents of the medical record (relevant history, physical exam, and diagnostic test results).