Sleep studies

Applies to:

All plans 

Sleep studies authorizations

Not required for in-home sleep studies/home sleep tests (HSTs).

If the result of an HST is negative in a patient suspected of having OSA, the patient can be referred to a certified sleep specialist for evaluation. This evaluation does not require prior authorization.

Authorization is required for attended/in-center sleep studies.

Please request an in-center study initially (95810) even if a possible split night could be completed. Do not request the two codes together.

Authorizations for an in-center sleep study (95810) will cover a split-night study (95811) that is completed during the initial night.

Medical policy

Obstructive Sleep Apnea - 91333

In-center sleep study billing

Payable:

  • When used to diagnose OSA and sleep disorders other than OSA.
  • When ordered and interpreted by a certified sleep specialist.
  • If the study results include a recommendation for the appropriate progressive airway pressure (PAP) dose following an APAP trial by the sleep specialist who interprets the study results.
  • If you receive an approval for the In Center Study 95810 and complete a Split night instead your 95811 claims will still be paid to the authorization. You do not need to update your auth or request a new one.

In-home sleep test billing

Payable:

Only when used to diagnose obstructive sleep apnea (OSA) and results are interpreted by an American Board of Sleep Medicine (ABSM) certified sleep specialist.

Not payable:

For general screening of asymptomatic patients.

Sleep studies coverage

Home-based studies that measure 3 or fewer physiologic parameters are not covered.

In-center sleep studies may be used to diagnose sleep disorders other than obstructive sleep apnea.

Also see: