Sleep studies

Applies to:

All plans

Definition

There are four levels of sleep tests based on the number of physiologic parameters measured:

  • Type 1 sleep studies: Performed in a sleep laboratory, record at least 12 physiologic parameters
  • Type 2 studies: Home-based, record 7 or more physiologic parameters
  • Type 3 studies: Home-based, record 4-7 physiologic parameters
  • Type 4 studies: Home-based, measure 3 or fewer physiologic parameters

In-home sleep tests (HSTs) are performed:

  • With an oral appliance to monitor the patient's response
  • At a reduced out-of-pocket liability

In patients with a high pre-test probability for moderate to severe OSA, research shows that HSTs are non-inferior to in-center studies. In fact, there was no difference in post test sleepiness scores, sleep quality, quality of life, blood pressure and CPAP adherence.

Medical policy

Obstructive Sleep Apnea - 91333

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:

Obstructive sleep apnea services

PAP therapy services

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.

Required for in-center sleep studies. Authorizations cover a split-night study that is completed during the initial night of testing.

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.

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