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
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
Authorization tools
Request a new authorization or check an auth's status.