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
Sleep Apnea: Obstructive and Central - 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.