Sleep Studies (for Kansas Only)
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.
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.
Coverage Criteria and Scope
Delegated clinical criteria
Clinical coverage is determined by external criteria sources and state requirements:
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
| 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. |
| 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. |
| 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. |
Prior Authorization, Documentation, and Provider Responsibilities
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.
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.
Documentation must fully support medical necessity
The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the medical record, and made available upon request.
- Include relevant medical history and physical exam findings.
- Attach results of pertinent diagnostic tests or procedures to the record.
- Maintain legible documentation and produce it upon request.
Denial risk for insufficient documentation
Lack of adequate medical record documentation supporting medical necessity may result in denial or non-coverage of the requested service.
- Incomplete, illegible, or absent documentation can lead to benefits denial.
- Medical records may be requested to assess whether the member meets clinical criteria; absence of supporting records does not guarantee coverage.
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
Policy Changes and Revision History
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).
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