ModifiedUnitedHealthcarePolicy CS098NE.B

Sleep Studies (for Nebraska Only)

Medical policy governing indications, coverage, and definitions for home and attended sleep studies and related daytime testing for members in Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicySleep Studies (for Nebraska Only)

Policy CodePolicy CS098NE.B

Change TypeRevisions and clarifications to HSAT/PSG criteria

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionAfter a single negative, inconclusive, or technically inadequate HSAT, proceed to attended full-channel polysomnography rather than repeating HSAT and document prior HSAT timing/results.

SourceLink

POLICY UPDATE CHANGES

Added notation that performing a repeat HSAT is not recommended when an initial test is negative, inconclusive, or technically inadequate; after a single such result, performance of attended full-channel polysomnography is strongly recommended.

Revised coverage criteria for attended full-channel polysomnography to reference previous HSAT within the past 12 months rather than unspecified prior HSAT timing.

Replaced MSLT language to state MSLT is medically necessary for evaluating suspected narcolepsy when other causes of excessive sleepiness have been excluded.

Language for repeat attended full-channel polysomnography and repeat PAP titration clarified to be medically necessary for individuals with persistent or new symptoms despite documented appropriate treatment; added clinical indications including clinically significant weight change (≥10%) or changes in cardiovascular disease since last study.

Removed reference to InterQual ® CP for Maintenance of Wakefulness Testing (MWT) from medical necessity clinical coverage criteria.

Explicit requirements about medical records documentation were added: medical record must support medical necessity, include relevant history/physical and test results, be legible and available upon request.

Supporting Information, Clinical Evidence and References sections were updated to reflect the most current information and previous policy version CS098NE.A was archived.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

1state-specific (NE only)

4+study types with coverage stance

≥4hminimum HSAT monitoring time

≥10%weight change threshold

02/01/2026policy effective date

Coverage Criteria — Sleep Studies and Daytime Testing

Home Sleep Apnea Testing (HSAT) — Indication

HSAT is medically necessary for evaluating adults with suspected OSA.

HSAT indication: HSAT using a portable monitor is medically necessary for evaluating adults with suspected Obstructive Sleep Apnea (OSA).

APAP may be used to determine fixed PAP pressure.

Attended Full-channel Polysomnography — Indications for Suspected OSA

Attended full-channel polysomnography is medically necessary when ANY of the following are met:

Attended polysomnography for suspected OSA: Results of previous (within the past 12 months) HSAT are negative, indeterminate, or technically inadequate to make a diagnosis of OSA.within 12 months

Kapur et al., 2017; CMS

Age criterion: Individual is a child or adolescent (<18 years of age).<18 years

Comorbid conditions prohibiting HSAT: Individual has one or more specified comorbid medical conditions that prohibit the use of a HSAT (significant chronic pulmonary disease with FEV1% predicted <60; progressive neuromuscular or neurodegenerative disorder; moderate to severe heart failure NYHA III/IV or LVEF ≤40; BMI >50; obesity hypoventilation syndrome; documented ongoing epileptic seizures with sleep disorder symptoms; chronic opiate medication use >3 months).FEV1% <60; BMI >50; LVEF ≤40

See policy for full list of examples and references.

Attended Polysomnography — Other Indications

Attended full-channel polysomnography is medically necessary when clinical assessment suggests one of the following:

Periodic Limb Movement Disorder: Evaluation for Periodic Limb Movement Disorder (PLMD) not due to another disorder.

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

Parasomnia suspicious for RBD: Parasomnia with documented disruptive, violent, or potentially injurious sleep behavior suspicious for REM Sleep Behavior Disorder (RBD).

Narcolepsy, once other causes of excessive sleepiness have been excluded by appropriate clinical assessment (see Daytime Sleep Studies for MSLT guidance).

Attended PAP Titration

When criteria for attended polysomnography 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.

AASM suggests split-night protocol when clinically appropriate.

Full-night titration: A full-night study for PAP titration when a split-night study is inadequate or not feasible and the individual has a confirmed diagnosis of OSA.

Used to determine optimal PAP pressure when split-night is not possible.

Attended Repeat Testing

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

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

Documented attempts to address technical/medical contributors should be in the record.

Significant weight or CV change: Clinically significant weight loss or gain (≥10%) or changes in cardiovascular disease since the last study.≥10%

References Caples et al., 2021; Peppard et al., 2000

Daytime Sleep Studies (MSLT, MWT)

Indications and limitations for daytime studies:

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

MSLT is not routinely indicated in initial OSA evaluation or for post-CPAP assessment unless excessive sleepiness persists.

MWT is medically necessary for evaluating an adult who is unable to stay awake resulting in a safety issue, or for assessing response to treatment in adults with sleep disorders; MWT is not medically necessary in children/adolescents <18 years of age.

AASM practice parameter supports MWT for assessing ability to remain awake in safety-sensitive situations.

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

PAP-Nap described in literature but considered investigational/insufficiently validated for routine coverage.

OSA diagnostic thresholds

Diagnostic criteria and testing approach references

OSA diagnosis thresholds: Diagnosis of OSA is confirmed if PSG-observed obstructive events are >15 events/hour in the absence of associated symptoms, or ≥5 events/hour when associated symptoms are present (unintentional sleep episodes, daytime sleepiness, unrefreshing sleep, fatigue, insomnia, gasping/choking, or bed partner–reported loud snoring or breathing interruptions).AHI/RDI >15 or ≥5 with symptoms

Per AASM (Epstein et al., 2009).

Testing modality selection and follow-up

Selection of home vs in-laboratory testing and PAP titration pathways

High pretest probability pathway equivalence: For individuals with a high pretest probability of OSA, ambulatory HSAT/portable-monitor diagnostic testing with appropriate follow-up and home APAP titration can achieve similar functional outcomes and CPAP adherence compared to in-laboratory PSG-based pathways.

Supported by randomized and comparative studies (e.g., Kuna et al., 2011) and systematic reviews.

When to use in-lab PSG: If HSAT is normal or technically inadequate in a high-risk individual, AASM recommends in-laboratory PSG; technical failure rates for unattended monitoring vary (3%–33%) and devices with audible alarms have lower failure rates (~2%).

From Collop et al., 2007; Levendowski et al., 2009.

PAP-Nap

PAP-Nap as adjunctive intervention for PAP-intolerant individuals

PAP-Nap evidence and usage: PAP-Nap combines psychological and physiological desensitization during a nap to improve PAP acceptance and short-term adherence in selected patients who refuse standard titration; pilot and retrospective studies show higher initiation and early adherence but larger prospective trials are needed to establish clinical value.

Krakow et al., 2008 pilot and Ulibarri et al., 2020 retrospective review.

Actigraphy

Actigraphy role and limitations

Actigraphy limitations: Current evidence is limited and does not validate actigraphy as a stand-alone diagnostic tool for most sleep disorders (including central hypersomnia, insomnia, or OSA); actigraphy may provide objective data complementary to sleep logs but impact on treatment decisions is unclear.

ECRI and Hayes reports; systematic reviews highlight inconsistent findings and risk of bias.

Testing selection and indications

Coverage and testing approach summary based on guideline recommendations

HSAT vs PSG selection: HSAT may be used for diagnosis of OSA in appropriate patients; PSG is the standard when clinical concerns (significant cardiorespiratory disease, neuromuscular disease, awake hypoventilation, chronic opioid use, history of stroke, or severe insomnia) are present.

AASM recommends PSG rather than HSAT in patients with significant comorbidities.

After non-diagnostic HSAT: If a single HSAT is negative, inconclusive, or technically inadequate, perform PSG rather than repeat HSAT.single prior HSAT

AASM strongly recommends PSG after one non-diagnostic HSAT.

MSLT indication: MSLT is medically necessary for evaluation of suspected narcolepsy when other causes of excessive sleepiness have been excluded by appropriate clinical assessment.

MSLT is not routinely indicated in initial OSA evaluation or for post-CPAP assessment unless excessive sleepiness persists.

PAP-Nap / Daytime studies

Daytime acclimation/desensitization (PAP-Nap)

PAP-Nap evidence: PAP-Nap has limited evidence (pilot and retrospective studies) suggesting improved PAP initiation and adherence in select patients resistant to standard titration; further large prospective trials are needed to establish clinical value.

Descriptive/experimental; not established as standard coverage indication.

HSAT and Attended Polysomnography Criteria

Revised coverage rationale and criteria excerpts present in this segment:

Attended polysomnography when prior HSAT non-diagnostic: Attended full-channel polysomnography is indicated when prior HSAT (within the past 12 months) are negative, indeterminate, or technically inadequate to make a diagnosis of OSA.prior HSAT within 12 months

Revised wording replaces prior unspecified timeframe.

Repeat HSAT discouraged: Performing a repeat HSAT is not recommended when an initial test is negative, inconclusive, or technically inadequate; attended full-channel polysomnography is strongly recommended instead.single prior HSAT

Operational recommendation to avoid repeat HSAT due to high likelihood of repeat non-diagnostic result.

Repeat attended polysomnography / PAP titration: Repeat attended full-channel polysomnography and repeat PAP titration are medically necessary for individuals with persistent or new symptoms despite documented appropriate treatment or PAP therapy, or who have experienced clinically significant weight loss or gain (>=10%) or changes in cardiovascular disease since the last study.

Attended full-channel polysomnography is not medically necessary for evaluation of Circadian Rhythm Disorders, Depression, or Insomnia. Actigraphy also is listed among studies considered not medically necessary for the evaluation of sleep disorders in these contexts.

Abbreviated daytime sleep studies (for example, PAP-Nap) are not medically necessary for routine diagnostic use due to insufficient evidence of efficacy. Small pilot and retrospective reports describe the PAP-Nap protocol (a 100-minute nap combining desensitization techniques and PAP exposure) and suggest improved short-term initiation and adherence in selected, PAP-reluctant patients, but larger prospective randomized studies are required to establish clinical value.

Current evidence does not support actigraphy as a stand-alone diagnostic modality for central hypersomnia, insomnia, or obstructive sleep apnea. Systematic reviews and assessments (ECRI, Hayes, Smith et al.) conclude available studies are limited in number and quality, show inconsistent agreement with conventional sleep testing, and do not demonstrate clear impact on treatment decisions or outcomes.

Routine multiple-night HSAT recordings are not supported by sufficient evidence. The AASM found limited data comparing multi-night recordings to a single-night HSAT and concluded the evidence is insufficient to demonstrate superiority of a multiple-night protocol; therefore, routine performance of more than a single night's HSAT is not recommended.

Operational guidance discourages repeating an HSAT after a single negative, inconclusive, or technically inadequate study. Because a second unattended test is likely to be similarly non-diagnostic and may delay completion of the diagnostic pathway, the policy strongly recommends proceeding to an attended full‑channel polysomnography (PSG) rather than performing a repeat HSAT.

This policy is intended to be applied consistently with governing benefit terms. In the event of any conflict between this policy and applicable federal, state, or contractual requirements for benefit plan coverage, the federal, state, or contractual requirements govern and should be followed.

As a reinforcement of coverage stance, both actigraphy and abbreviated daytime sleep studies (e.g., PAP-Nap) are considered not medically necessary for routine diagnostic use due to insufficient evidence of effectiveness; actigraphy is not validated as a sole diagnostic test and PAP-Nap lacks adequate prospective outcome data.

Use of actigraphy alone to diagnose central hypersomnia, insomnia, or obstructive sleep apnea is not supported by sufficient evidence and therefore is not accepted as a standalone diagnostic approach; actigraphy may provide complementary objective data but should not replace standard diagnostic testing when clinical decisions depend on definitive diagnosis.

PAP-Nap is considered investigational or insufficiently validated for routine coverage. Available evidence consists of small pilot and retrospective series that report improved short-term PAP initiation and adherence in select patients who refused standard titration, but the evidence base lacks large prospective randomized trials necessary to support routine reimbursement.

Coding — Relevant CPT/HCPCS and Key Parameters

Polysomnography and related CPT codesCPT

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.

Polysomnography and Home Sleep Test HCPCS/CPTmixed

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.

Daytime study example referencedCPT

CPT 95807-52

Daytime, abbreviated cardio-respiratory sleep study (PAP-NAP) — as referenced in source

inv-26: Clinically significant weight change (key value)

DefinitionClinically significant weight change is defined as a change in body weight of ≥ 10% since the last study.

Use in repeat testing criteriaClinically significant weight loss or gain (≥ 10%) is a listed indication for repeat attended full-channel polysomnography or repeat PAP titration.

Supporting referencesReferenced studies and policy revision notes cite Caples et al., 2021 and Peppard et al., 2000 in the context of weight change affecting need for repeat testing.

inv-27: Minimum HSAT monitoring time

Minimum monitoring timeAdequate HSAT occurs over a minimum of 4 hours of monitoring time.

Provider Actions and Documentation Requirements

Note

State-specific policy

This policy applies only to the State of Nebraska. Verify state-specific applicability before submitting requests or documentation.

Applies to: Nebraska only

Billing Rule

Code reference and prior authorization implication

The following codes are provided for reference only. Inclusion does not guarantee coverage or payment; check the member's benefit plan for prior authorization or coverage rules.

CPT/HCPCS/other codes listed in policy are for reference and are not a guarantee of payment
Listing of codes does not imply coverage — verify benefits and prior authorization requirements

Background and Rationale

Background: Obstructive sleep apnea (OSA) and other sleep disorders are evaluated using a mix of modalities. HSAT can diagnose OSA in appropriate adults, while attended full‑channel polysomnography (PSG) is indicated when comorbidities, pediatric age, or previous non-diagnostic HSAT results apply. Daytime tests (MSLT/MWT) are reserved for hypersomnolence evaluation; actigraphy and abbreviated daytime studies have limited supporting evidence and are not substitutes for PSG or validated HSAT pathways.

Definitions

inv-56: Apnea definition (key value)

Event definitionApnea: cessation of airflow defined as ≥ 90% decrease in airflow sensor excursions from baseline lasting at least 10 seconds; classified as obstructive, central, or mixed based on respiratory effort.

Obstructive apneaAssociated with continued or increased inspiratory effort throughout the period of absent airflow.

Central apneaAssociated with absent inspiratory effort throughout the period of absent airflow.

inv-57: Home Sleep Apnea Testing (HSAT) definition and minimum monitoring time

DefinitionHome Sleep Apnea Testing (HSAT): Unattended diagnostic studies to assess for OSA without determination of sleep stage.

Minimum monitoring time

Revision History and Policy Changes

2026-02-01policy_revisionLatest

Effective 2026-02-01, revised coverage rationale: added guidance that performing a repeat HSAT is not recommended after a single negative, inconclusive, or technically inadequate HSAT and that attended full‑channel polysomnography is strongly recommended instead; clarified attended PSG criteria to require prior HSAT within the past 12 months when applicable.

2026-02-01policy_revision

Revised daytime sleep study language: MSLT wording narrowed to state MSLT is medically necessary for evaluating suspected narcolepsy when other causes of excessive sleepiness have been excluded.

2026-02-01

Policy Summary

PayerUnitedHealthcare

PolicySleep Studies (for Nebraska Only)

Policy CodePolicy CS098NE.B

Change TypeRevisions and clarifications to HSAT/PSG criteria

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionAfter a single negative, inconclusive, or technically inadequate HSAT, proceed to attended full-channel polysomnography rather than repeating HSAT and document prior HSAT timing/results.

SourceLink

On This Page

Central Sleep Apnea:

Evaluation of Central Sleep Apnea.

Follow-up PSG/HSAT: Follow-up PSG or HSAT is not recommended for routine reassessment of asymptomatic OSA patients on PAP; may be used for recurrent or persistent symptoms despite adherence, to assess response to non-PAP interventions, clinically significant weight change, new/existing cardiovascular disease, or unexplained device-generated data.

Based on AASM clinical guidance.

Added clinical indications for repeat testing.

Required sensors (minimum)HSAT should include at least nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry.

Monitoring time definition noteMonitoring Time excludes periods of artifact and time awake as determined by actigraphy, body position sensor, respiratory pattern, or diary.

inv-28: OSA severity (AHI or RDI) thresholds

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-29: PAP-Nap duration

PAP-Nap durationThe PAP-Nap protocol includes a 100-minute nap period for combined desensitization and physiological exposure.

PurposeDesigned as a daytime abbreviated cardio-respiratory study to improve PAP acceptance in patients who refuse full titration or in-home PAP trials.

Evidence statusPilot and retrospective data exist but larger prospective trials are needed to establish clinical value.

inv-30: Clinically significant weight change (duplicate key value)

DefinitionClinically significant weight change is defined as a change in body weight of ≥ 10% since the last study.

Role in repeat testingA ≥ 10% weight change is an explicit clinical indication for repeat attended polysomnography or PAP titration per policy revisions.

Policy revision contextLanguage adding ≥ 10% threshold for repeat testing was included in the policy's recent revisions and summary of changes.

Prior Authorization

HSAT results and requirement for polysomnography

If a Home Sleep Apnea Test (HSAT) is negative, inconclusive, or technically inadequate, a repeat HSAT is not recommended. After a single non-diagnostic HSAT, attended full‑channel polysomnography (PSG) is strongly recommended (preferably performed in a healthcare facility or laboratory).

Repeat HSAT discouraged; attended PSG recommended after one non-diagnostic HSAT
If previous HSAT within past 12 months is negative/indeterminate/technically inadequate, PSG may be indicated

Prior Authorization

Prior authorization not specified — consult plan

This excerpt does not specify a uniform prior authorization process. Providers must consult the member's benefit plan for any plan-specific prior authorization or precertification requirements before scheduling testing or treatment.

Prior authorization: not specified in this policy excerpt
Action: check the member's plan for prior authorization requirements

Billing Rule

Code listing caveat

Codes included in the policy are illustrative. Listing of a code in this policy does not imply that the service described is covered; it does not guarantee reimbursement or claim payment.

Inclusion of a code is not a guarantee of coverage or payment
Confirm coverage against the member's federal/state/contractual benefit terms

Denial Risk

Documentation insufficiency may result in denial

If medical records do not fully support the clinical criteria or medical necessity for the requested service, coverage may be denied. Documentation should be complete, legible, and available upon request.

Insufficient documentation may result in denial
Maintain legible records of relevant history, exam, and diagnostic test results

Note

No explicit authorization or denial trigger in this excerpt

This policy excerpt does not establish an explicit automatic approval or denial trigger. Coverage decisions must be made in light of the member's specific plan terms and the documented medical necessity.

No explicit authorization/denial trigger in this excerpt
Use clinical judgment and plan rules to determine coverage

Note

Conflict with plan requirements — verify governing rules

Benefit coverage is governed by the applicable federal, state, or contractual requirements. In the event of any conflict between this policy and benefit-plan or legal requirements, the federal/state/contractual terms govern.

Verify and follow federal, state, and contractual benefit requirements
In conflicts, governing requirements supersede this policy

Documentation Required

Medical records requirements

The patient's medical record must fully support medical necessity for requested services. Documentation should include relevant history, physical exam findings, and pertinent diagnostic test results, be legible, maintained in the record, and produced upon request.

Required documentation: medical history, physical exam, diagnostic test results
Records must be legible and available upon request

Documentation Required

Study setting documentation

Different study settings have different implications: HSAT is performed unattended at home; Polysomnography (PSG) is attended and performed in-lab. Document the setting used and any technician attendance or lack thereof.

HSAT = unattended, performed at home
PSG = attended, performed in a laboratory/healthcare facility
If using split-night PSG, document diagnostic and titration portions

Note

Verify governing benefit and plan requirements

Before applying this policy to coverage decisions, verify the member's governing benefit requirements and any plan-specific rules or tools (e.g., InterQual) that UnitedHealthcare may use to administer benefits.

Check the member's federal/state/contractual benefit terms
UnitedHealthcare may use third-party tools; confirm applicability

Note

APAP option and PAP titration requirement after OSA diagnosis

When HSAT is indicated, an autotitrating PAP (APAP) may be used as an option to determine a fixed PAP pressure. If OSA is diagnosed, a PAP titration (attended or split-night) is required to establish therapeutic pressure.

APAP may be used when HSAT indicates OSA to determine fixed PAP pressure
PAP titration (attended PSG or split-night) is required after diagnosis to determine optimal pressure

Step Therapy

Step therapy not specified in this excerpt

No step therapy requirements are specified in this excerpt. Consult the member's plan for any applicable step-therapy or coverage sequencing rules.

Step therapy: not specified here — check plan-specific requirements

Note

Not applicable in this excerpt

Not applicable in this excerpt: any additional provider actions or restrictions not explicitly described here should be verified against the full policy and the member's benefit plan.

If a provider action is not covered in this excerpt, consult the full policy and plan documents

Adequate HSAT requires a minimum of 4 hours of monitoring time.

Minimum sensorsAdequate HSAT includes at least nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry.

inv-58: Obstructive Sleep Apnea (OSA) severity categories

MildAHI or RDI ≥ 5 and < 15 events/hour.

ModerateAHI or RDI ≥ 15 and ≤ 30 events/hour.

SevereAHI or RDI > 30 events/hour.

inv-59: Parasomnia definition

DefinitionParasomnia: Undesirable physical events or experiences occurring during entry into sleep, within sleep, or during arousal; characterized by abnormal movements, behaviors, emotions, perceptions, dreams, and autonomic activity, often causing injury or sleep disruption.

OccurrenceMay occur during NREM sleep, REM sleep, or sleep-wake transitions.

Clinical significanceConsidered a clinical disorder when causing injury, sleep disruption, or psychosocial effects.

inv-60: Polysomnogram (Attended) definition

DefinitionPolysomnogram (Attended): Laboratory-based sleep study using multiple channels to record brain activity, eye movements, body movements, breathing and heart rate with a technologist present.

SettingPerformed in a sleep laboratory with technologist attendance.

ScopeCaptures full-channel physiologic data including sleep staging.

inv-61: PAP types definition

CPAPContinuous Positive Airway Pressure: delivers a steady, fixed pressure on inhalation.

BPAPBilevel Positive Airway Pressure: delivers higher inspiratory than expiratory pressure.

APAP and ASVAPAP: autotitrating PAP that adjusts pressure based on breathing patterns; ASV: adaptive servoventilation that adjusts breath-by-breath to maintain ventilation.

inv-62: RDI/REI definitions

RDIRespiratory Disturbance Index: Apneas + Hypopneas + RERAs per hour of sleep (events/hour).

REI (HSAT)Respiratory Event Index: total respiratory events scored per monitoring time (events/hour); used as a surrogate for AHI in HSAT recordings.

Relation to AHIAHI and RDI are reported as events per hour; REI is used when sleep time is not directly measured (portable monitors).

inv-63: Restless Legs Syndrome (RLS) definition

DefinitionRestless Legs Syndrome (RLS): A sensorimotor disorder characterized by a strong, nearly irresistible urge to move the limbs, often accompanied by uncomfortable sensations, most prominently affecting the legs.

Clinical impactSymptoms often occur at rest and can cause sleep disruption and daytime impairment.

TerminologyAlso referred to as Willis-Ekbom Disease.

inv-64: HSAT abbreviation definition

AbbreviationHSAT stands for Home Sleep Apnea Test.

SynonymAlso referred to as out-of-center sleep testing or portable monitoring.

ContextUsed as an unattended diagnostic alternative to in-lab PSG for appropriate adult patients.

inv-65: PSG abbreviation definition

AbbreviationPSG stands for Polysomnography (attended full-channel in-lab study).

Alternate termAlso abbreviated as PSG when referring to in-laboratory attended studies with technologist oversight.

UseConsidered the standard diagnostic test for OSA when comorbidities or non-diagnostic HSAT are present.

inv-66: MSLT definition

DefinitionMultiple Sleep Latency Test (MSLT): A daytime sleep study measuring physiological sleep tendency under standardized conditions; used primarily to confirm narcolepsy and differentiate causes of pathological sleepiness.

Indication noteMSLT is not routinely indicated in initial OSA evaluation but is medically necessary for evaluating suspected narcolepsy when other causes of excessive sleepiness have been excluded.

Test purposeAssesses propensity to fall asleep across multiple standardized trials during the day.

inv-67: PAP-Nap definition

DefinitionPAP-Nap: A daytime abbreviated cardio-respiratory protocol combining mask and pressure desensitization, emotion-focused therapy, mental imagery, and physiological PAP exposure during a nap to improve subsequent PAP acceptance.

DurationTypical PAP-Nap includes a 100-minute nap period as part of the procedure.

Evidence statusEvidence consists of pilot and retrospective studies; further large prospective studies are needed before routine coverage is established.

inv-68: Prior HSAT (definition — within past 12 months)

DefinitionPrior HSAT: a Home Sleep Apnea Test performed within the past 12 months.

Policy useResults of a prior HSAT within 12 months that are negative, indeterminate, or technically inadequate are referenced in the criteria for proceeding to attended PSG.

Revision notePolicy language was revised to specify the 12-month timeframe for prior HSAT when determining PSG indications.

inv-69: Clinically significant weight change definition

DefinitionClinically significant weight change: a weight loss or gain of ≥ 10% since the last study.

Role in policyUsed as an explicit indication for repeat attended full-channel polysomnography or repeat PAP titration when patients have experienced such weight change.

Referenced evidencePolicy revisions and supporting references (Caples et al., Peppard et al.) cite weight change as relevant to need for repeat testing.

Clarified repeat attended PSG and PAP titration criteria to include individuals with persistent or new symptoms despite treatment and added clinically significant weight change (≥10%) or changes in cardiovascular disease as indications for repeat testing.

2026-02-01policy_update

Added explicit medical records documentation requirements: coverage determined by applicable laws/contract, records must support medical necessity, include relevant history/physical and test results, be legible and made available upon request.

2026-02-01administrative

Updated Supporting Information, Clinical Evidence and References sections to reflect current information and archived previous policy version CS098NE.A.

Prior authorization requirements are not specified in this policy text. Providers should consult the applicable plan or contractual documents for any prior authorization rules that apply to sleep studies or related services.