Sleep Studies (for New Mexico Only)
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This policy governs coverage and medical necessity criteria for sleep studies (home and attended polysomnography, daytime tests) for UnitedHealthcare members in New Mexico.
Replaced requirement that prior HSAT results be 'negative, indeterminate, or technically inadequate' with 'negative or indeterminate' to make a diagnosis of OSA.
Broadened attended PAP titration indication language from requiring a confirmed diagnosis of OSA to allowing a full-night PAP titration when the individual has a confirmed diagnosis of OSA or other sleep-disordered breathing.
Clarified that repeat attended full-channel polysomnography and repeat PAP titration are medically necessary only when the criteria for an attended study are met.
Updated definition of 'Polysomnography (Attended)'.
Removed change in cardiovascular disease from the list of circumstances for repeat testing; retained clinically significant weight change (≥ 10%).
Coverage and Medical Necessity Criteria
HSAT (Home Sleep Apnea Testing)
Covered when ALL of the following are met:
Where HSAT is indicated, an autotitrating Positive Airway Pressure (APAP) device may be used to determine a fixed PAP pressure; repeat HSAT after a single negative, inconclusive, or technically inadequate HSAT is not recommended — perform attended full-channel polysomnography instead.
Attended PSG — Suspected OSA
Covered when ANY of the following are met:
Replaces prior language that included 'technically inadequate' HSAT results.
Attended full-channel PSG is indicated for pediatric patients.
Examples include: FEV1% predicted < 60% (significant chronic pulmonary disease); progressive neuromuscular disease; NYHA class III/IV heart failure or LVEF ≤ 40%; BMI ≥ 50; obesity hypoventilation syndrome; documented ongoing epileptic seizures with sleep disorder symptoms; chronic opiate medication use > 3 months.
Attended PSG — Other Conditions
Covered when appropriate clinical assessment suggests ANY of the following:
Daytime Sleep Studies (MSLT, MWT)
Covered when ALL of the following are met for each test:
MSLT is typically performed after an overnight PSG; refer to InterQual for detailed clinical coverage.
MWT is unproven and not medically necessary in children and adolescents <18 years.
PAP Titration and Repeat Testing
Covered when ALL of the following are met:
See Repeat Testing criteria for circumstances requiring repeat titration.
Repeat testing is medically necessary only when criteria for an attended study are met.
Not Medically Necessary — Other Studies
General coverage considerations for sleep testing
Diagnostic and testing selection considerations summarized from the policy and referenced guidelines:
Definitions and device classifications (AASM Type 1-4) and guidance from AASM/American Thoracic Society are referenced.
Evidence and definitions provided in policy references.
Policy cites studies on night-to-night variability and data loss for unattended monitoring.
Revised coverage criteria highlights
Summary of material revisions affecting coverage criteria:
This is a material change in the attended PSG criteria.
Clarifies titration indications.
Revisions restrict repeat testing to situations meeting attended study criteria.
The policy lists certain attended full-channel polysomnography (PSG) indications as not medically necessary. Specifically, PSG performed solely to evaluate Circadian Rhythm Disorders, Depression, or Insomnia is considered not medically necessary due to insufficient evidence of benefit. In addition, the policy deems actigraphy for any sleep disorders not medically necessary as a diagnostic substitute for conventional testing in these contexts.
Providers should note that sleep studies are not covered for Alternative Benefit Package (ABP) members age 21 and over. This coverage limitation applies to the patient population described and may affect prior authorization and claims adjudication for ABP members.
The policy summarizes the clinical evidence regarding actigraphy and states that current evidence is very limited and does not establish actigraphy as an effective stand-alone diagnostic tool for sleep disorders. Systematic reviews and technology assessments cited in the policy found insufficient quantity and quality of studies to validate actigraphy as an alternative to conventional sleep studies for central hypersomnolence, insomnia, or obstructive sleep apnea.
Clinical practice guidance from the American Academy of Sleep Medicine (AASM) is cited in the policy and includes a strong recommendation that actigraphy should not be used in place of electromyography (EMG) for the diagnosis of periodic limb movement disorder (PLMD) in adults and pediatric patients. The policy aligns with this guidance and indicates actigraphy is not a substitute for EMG when diagnosing PLMD.
The most recent revision clarified and replaced some previously worded criteria but did not introduce new explicit exclusions in the cited sections. Changes included wording updates to prior HSAT result requirements and broadened PAP titration indications; however, the document does not add new named exclusions beyond those already present.
Consistent with the exclusions, the policy considers attended full-channel PSG for Circadian Rhythm Disorders, Depression, or Insomnia to be not medically necessary. The policy also reiterates that actigraphy is considered not medically necessary as a diagnostic replacement for conventional sleep testing across sleep disorders due to limited and inconsistent evidence.
The policy states that available studies and reviews do not validate actigraphy as a reliable stand-alone test for narcolepsy, insomnia, or obstructive sleep apnea (OSA). Reviews cited found that the quantity and quality of diagnostic studies were insufficient to support actigraphy as an alternative to conventional polysomnography or other established diagnostic modalities.
The sections referenced for not medically necessary content in these chunks do not contain separate full NMN statements; rather, NMN determinations for some tests are stated elsewhere in the policy. The revision notes in the policy indicate wording changes and clarifications but point readers to other sections for the complete NMN language.
Procedure Codes, Severity Thresholds, and Coding Guidance
| 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. |
| 95807-52 | Daytime, abbreviated cardio-respiratory sleep study (PAP-Nap) - as cited in Krakow et al. 2008 |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization and applicability — New Mexico only
Policy applies only to UnitedHealthcare members in New Mexico and sets specific coverage criteria for HSAT, attended full‑channel polysomnography (PSG), daytime studies (MSLT/MWT), PAP titration (including split‑night), and repeat testing. Use the policy sections to determine which test is appropriate and whether prior authorization is required for the requested service.
Reference procedure codes provided for prior authorization
The policy provides a list of procedure and HCPCS/CPT codes for attended PSG, HSAT/HST, MSLT, actigraphy, and related studies for reference in prior authorization and billing; inclusion of a code does not guarantee coverage.
Device FDA clearance is informational only
FDA clearance information for PSG systems, HSAT devices, and actigraphy devices is provided for informational purposes only; FDA clearance alone does not determine coverage.
Attended studies require documentation that attended criteria are met
When requesting authorization for attended full‑channel PSG, attended PAP titration, or repeat attended studies, include documentation that the policy's criteria for an attended study are met (e.g., required prior HSAT results, comorbidity thresholds, age), or the request may be denied.
- Prior HSAT results: when the policy requires prior HSAT, results within 12 months must be negative or indeterminate (not 'technically inadequate').
- Comorbidities and age thresholds that mandate PSG (e.g., pediatric age <18, FEV1% predicted <60%, BMI ≥50) must be documented.
HSAT → APAP and when to proceed to attended PSG
When HSAT is indicated, autotitrating PAP (APAP) may be used to derive a fixed PAP pressure; after a single negative, indeterminate, or technically inadequate HSAT, a repeat HSAT is not recommended — perform attended full‑channel PSG instead.
- APAP can be used to determine fixed PAP pressure when HSAT is appropriate.
- Do not perform a repeat HSAT after a single negative, inconclusive, or technically inadequate result; authorize in‑lab PSG for definitive diagnosis.
PAP trial/titration (split‑night or full‑night) after diagnosis
After an OSA diagnosis, perform a PAP trial/titration to determine therapeutic pressure; split‑night PSG may be used for combined diagnosis and titration when appropriate, and a full‑night PAP titration is medically necessary when the individual has a confirmed diagnosis of OSA or other sleep‑disordered breathing.
- Split‑night studies combine diagnostic PSG and PAP titration into a single night when indicated.
- Full‑night PAP titration is allowed for confirmed OSA or other sleep‑disordered breathing per revised criteria.
Follow‑up testing: when to reassess with PSG or HSAT
Routine follow‑up PSG or HSAT is not recommended for asymptomatic patients who are adherent to PAP therapy; use follow‑up testing to reassess patients with recurrent/persistent symptoms, to assess response to non‑PAP interventions, or after clinically significant weight change or other relevant clinical changes.
- Follow‑up testing may be used for patients with recurrent/persistent symptoms despite good PAP adherence.
- Follow‑up PSG or HSAT may be used after clinically significant weight gain or loss, to assess sleep‑related hypoxemia/hypoventilation, or for unexplained PAP device data.
Medical record requirements — documentation must support medical necessity
The patient's medical record must contain legible documentation supporting medical necessity for the requested sleep study, including relevant medical history, physical exam findings, and prior diagnostic test results; records must be available upon request.
- Include prior HSAT results (when applicable), results of prior PSG, evidence of clinically significant weight change (≥ 10%) when repeat testing is requested, and documentation of symptoms/comorbidities prompting an attended study.
Operational distinction — PSG (attended) vs HSAT (unattended)
PSG is an attended, in‑laboratory study performed with a sleep technologist and records multiple physiologic channels; HSAT is an unattended, at‑home study that records respiratory and oximetry parameters — document which modality was used and rationale for selecting PSG over HSAT when applicable.
- PSG: attended in a laboratory with EEG, EOG, EMG, respiratory and cardiac channels and a technologist present.
- HSAT: unattended at home, records respiratory airflow, effort, oximetry and heart rate depending on device type.
Documentation of diagnostic pathway and follow‑up — PSG is the standard when concern exists
Perform diagnostic evaluation and follow‑up for suspected OSA with a comprehensive sleep evaluation; PSG remains the diagnostic standard when clinical concern exists and must be used when HSAT is inadequate or contraindicated.
- Follow AASM guidance: use PSG or a technically adequate HSAT for diagnosis; if single HSAT is negative/inconclusive/technically inadequate, perform PSG.
- Document the diagnostic pathway and follow‑up plan in the medical record.
Documentation must support attended‑study criteria and prior HSAT results
Documentation for attended studies should show that criteria for an attended study are met, including prior HSAT results when required and evidence of clinically significant weight change (≥ 10%) or other qualifying clinical changes if repeat testing is requested.
- When prior HSAT is required, results within the past 12 months must be negative or indeterminate to support attended‑PSG diagnosis per revised criteria.
- For repeat attended PSG or repeat PAP titration, document clinically significant weight change (≥ 10%) since the prior study if that is the basis for repeat testing.
Denial risk — ABP members age 21+ not covered
Sleep studies requested for members enrolled in the Alternative Benefit Package (ABP) who are age 21 years or older are not covered; verify member benefit type before submitting authorization requests.
Code list inclusion does not imply coverage
Listing a CPT/HCPCS code in this policy is for reference only and does not imply the service described by that code is covered — benefit, federal/state, or contractual rules determine coverage and reimbursement.
Repeat HSAT after non‑diagnostic result — proceed to PSG, not another HSAT
If an initial HSAT is negative, indeterminate, or technically inadequate, do not perform a repeat HSAT for definitive diagnosis; instead, authorize and perform attended full‑channel PSG because repeat HSAT in this situation is generally not appropriate and may lead to denial of definitive diagnostic testing.
Denial risk if revised attended‑PSG criteria are not met
Failure to meet the revised coverage criteria for attended full‑channel PSG — for example, not demonstrating required prior HSAT results (negative or indeterminate within 12 months) when the policy requires them — may result in denial of coverage.
Background and Evidence Summary
Home Sleep Apnea Testing (HSAT) is an unattended diagnostic modality that assesses obstructive sleep apnea using portable monitors without full sleep staging. The policy requires that an adequate HSAT include a minimum of four hours of recording and appropriate sensors (for example, nasal pressure, respiratory inductance plethysmography, and oximetry). HSAT is appropriate for diagnosing OSA in selected adults when criteria in the policy are met; in-laboratory attended full-channel polysomnography is preferred when HSAT is inadequate or when comorbidities or other clinical scenarios require attended testing.
Key Definitions
Policy Updates and Material Changes
Revised attended full-channel polysomnography criteria: prior HSAT result requirement changed from 'negative, indeterminate, or technically inadequate' to 'negative or indeterminate' when required; clarified attended PSG indications and updated wording for parasomnia/RBD scenarios.
Updated attended PAP titration indication to allow a full-night PAP titration when the individual has a confirmed diagnosis of OSA or other sleep-disordered breathing (broadened from requiring a confirmed diagnosis of OSA only).
Clarified repeat testing language: repeat attended full-channel polysomnography and repeat PAP titration are medically necessary only when criteria for an attended study are met; retained clinically significant weight change (≥ 10%) as a circumstance for repeat testing and removed changes in cardiovascular disease from that list.
Updated the definition of 'Polysomnography (Attended)' in the policy document.
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