Local Coverage Determination
CPT Code/Search Topic
95805-95811
LMRP/LCD ID
L18819
LMRP/LCD Title
Outpatient Sleep Studies
Indications and Limitations of Coverage and/or Medical Necessity
The diagnostic evaluation of sleep disorders often requires overnight examination of the
sleeping patient by means of polysomnography to assess severity, effect on sleep
architecture and continuity, and the effects on gas exchange, cardiac function, etc.
Polysomnography is used in conjunction with the patient’s history, other laboratory tests
and observations, and the physician’s knowledge of sleep disorders to reach a diagnosis
and to recommend appropriate treatment and follow-up.
The accuracy of diagnostic sleep studies depends on the knowledge, skill, and experience
of the technologist and interpreter. Consequently, the providers of interpretations must be
capable of demonstrating documented training and experience and maintain
documentation for post-payment audit. (See "Documentation Requirements" section of
this policy for certification/ accreditation requirements.) Because patients referred for
sleep studies must be evaluated thoroughly, the participation of a physician in the
program is required. After evaluation, diagnosis, and the development of a treatment
plan, patients are usually returned to their referring physicians, some patients will elect at
least some treatment and follow-up with the sleep disorders program staff, particularly
for prescription refills, the follow-up of nasal CPAP, etc.
Studies may be performed in a freestanding center that is a direct extension of a
physician’s office if the center is accredited by either the American Academy of Sleep
Medicine (AASM) or the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). For studies performed in an Independent Diagnostic Testing
Facility (IDTF), please refer to policy AC-03-007, Independent Diagnostic Testing
Facilities (IDTF). (This policy is applicable for Part B services.)
Space, equipment, and staffing must be consistent with the AASM Standards of
Accreditation or accredited through JCAHO.
On December 6, 2003, implementation of the certification and accreditation requirements
was postponed pending development of an appropriate timeline. Below is the new
timeline for this requirement:


All studies are to be done by a certified polysomnographer by January 1, 2008;
and
All sleep studies are to be supervised and read by an ABSM Board Certified Sleep
Medicine physician by January 1, 2012.
All sleep studies must be performed in a Center/Laboratory that meets the following
criteria:
1. Each center/laboratory must have as medical director a physician with a license valid
in the state of the center.
2. Each center must be AASM or JCAHO accredited, have a Diplomate of the ABSM on
staff or an individual currently accepted by the ABSM to sit for its certification exam.
This individual may fulfill all the responsibilities of the board-certified sleep specialist in
a sleep disorders center.
3. Technicians must work under the direction and control of a licensed physician, even
though this test may be covered in the absence of direct supervision. This information
should be documented and available upon request.
4. Each center/laboratory must be accredited by and comply with the standards set by the
AASM or JCAHO.
For dates of service May 15, 2005 through January 1, 2012, each center must have on
staff (1) a physician who is a Diplomate of ABSM; (2) board eligible to sit for ABSM
certification exam; or (3) special training in sleep medicine with the specialty designation
of either pulmonary medicine, neurology, psychiatry, or otolaryngology. Ongoing yearly
or biannual training in sleep medicine with CMEs should be available upon request.
All reasonable and necessary diagnostic tests given for the medical conditions listed
below are covered if the criteria are met. Because it is not reasonable and necessary,
diagnostic testing that is duplicative of previous testing performed by the attending
physician, to the extent that the results are still pertinent, is not covered.
Diagnostic testing is covered only if the patient has the symptoms or complaints of one of
the conditions below. Most of the patients who undergo the diagnostic testing are not
considered inpatients, although they may come to the facility in the evening for testing
and then leave after their tests are over. The overnight stay is considered an integral part
of these tests.
Diagnosis-Based Recommendations:
Unless otherwise specified, these recommendations refer to attended polysomnography
studies and attended cardiorespiratory sleep studies.
I. Sleep-Related Breathing Disorders:
Disordered breathing during sleep consists of apnea defined as a cessation of airflow for
at least ten seconds. Hypopnea is defined as an abnormal respiratory event lasting at least
ten seconds with at least a 30% reduction in thoracoabdominal movement or airflow as
compared to baseline, and with at least a four percent oxygen desaturation.
The polysomnography must be performed in an accredited facility based sleep study
laboratory, and not in the home or in a mobile facility. Documentation in the medical
record for initial claims for CPAP devices must indicate the patient met stated coverage
criteria.
Disordered breathing during sleep is often associated with sleep fragmentation. The total
number of apneas and hypopneas per hour of sleep is the apnea-hypopnea index (AHI),
also referred to as the respiratory disturbance index. The total number of arousals per
hour of sleep from apneas, hypopneas, and periodic increases in respiratory effort is the
respiratory-arousal index.
Sleep Apnea (ICD-9-CM 780.51, 780.53, 780.55, 780.56, 780.57) episodes can be
documented by the appropriate diagnostic testing. Ordinarily, sleep apnea can be
diagnosed by a single polysomnogram and EEG which would require documentation of
an AHI that is equal to or greater than fifteen events per hour, or an AHI that is equal to
or greater than five and less than fourteen events per hour with documented symptoms of
excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, documented
hypertension, ischemic heart disease or history of stroke. The AHI is equal to the average
number of episodes of apnea and hypopnea per hour and must be based on a minimum of
two hours of sleep recorded by polysomnography using actual recorded hours of sleep
(i.e., the AHI may not be extrapolated or projected). Standard polysomnography/sleep
study is the accepted test for the diagnosis and determination of severity and treatment of
obstructive sleep apnea. The AASM defines standard polysomnography as including the
recording of electroencephalogram, electro-oculogram, chin electromyogram,
electrocardiogram, airflow, respiratory effort and oxygen saturation. Body position must
be documented or objectively measured. Trained personnel must be in constant
attendance and able to intervene. Leg movement recording (electromyogram or motion
sensor) is desirable but optional. Portable sleep studies are not indicated for the routine
assessment of obstructive sleep apnea and other sleep disorders.
Clinical indications for polysomnography and other sleep medicine procedures:
1. Polysomnography is routinely indicated for the diagnosis of sleep-related breathing
disorders.
2. Polysomnography is indicated for CPAP titration in patients with sleep-related
breathing disorders.
3. A preoperative clinical evaluation that includes polysomnography or cardiorespiratory
sleep study is routinely indicated to evaluate for the presence of obstructive sleep apnea
in patients before they undergo surgical intervention for snoring.
4. Follow-up polysomnography or a cardiorespiratory sleep study is routinely indicated
for the assessment of treatment results in the following circumstances:
a. After good clinical response to oral appliance treatment in patients with moderate to
severe obstructive sleep apnea, to ensure therapeutic benefit;
b. After surgical treatment of patients with moderate to severe obstructive sleep apnea, to
ensure satisfactory response; or
c. After surgical treatment of patients with sleep apnea whose symptoms return despite a
good initial response to treatment.
5. Follow-up polysomnography is routinely indicated for the assessment of treatment
results in the following circumstances:
a. After substantial weight loss has occurred in patients on CPAP for treatment of sleeprelated breathing disorders to ascertain whether CPAP is still needed at the previously
titrated pressure;
b. After substantial weight gain has occurred in patients previously treated with CPAP
successfully, who are again symptomatic despite the continued use of CPAP, to ascertain
whether pressure adjustments are needed; or
c. When clinical response is insufficient or when symptoms return despite a good initial
response to treatment with CPAP.
6. Follow-up polysomnography or a cardiorespiratory sleep study is not routinely
indicated in patients treated with CPAP whose symptoms continue to be resolved with
CPAP treatment.
7. A multiple sleep latency test is not routinely indicated for most patients with sleeprelated breathing disorders. A subjective assessment of excessive daytime sleepiness
should be obtained routinely. When an objective measure of daytime sleepiness is also
required, previously published practice parameters should be consulted.
II. Other Respiratory Disorders:
This diagnostic category includes breathing disorders that are not principally defined by
obstructive or central apnea or the upper-airway resistance syndrome.
Polysomnography is indicated for patients with neuromuscular disorder and sleep-related
symptoms to evaluate symptoms of sleep disorder that are not adequately diagnosed by
obtaining a sleep history, assessing sleep hygiene, and reviewing sleep diaries.
Polysomnography is not indicated to diagnose chronic lung disease. Nocturnal
hypoxemia in patients with chronic obstructive, restrictive, or reactive lung disease is
usually adequately evaluated by oximetry and does not require polysomnography.
However, if the patient’s symptoms suggest a diagnosis of obstructive sleep apnea or
periodic limb movement disorder, indications for polysomnography are the same as for
those disorders in patients without chronic lung disease.
III. Narcolepsy (ICD-9-CM 347.00-347.01, 347.10-347.11):
Narcolepsy is a neurologic disorder characterized predominantly by abnormalities of
REM sleep, some abnormalities of non-REM (NREM) sleep, and the presence of
excessive daytime sleepiness. The classic tetrad of narcolepsy symptoms includes
hypersomnolence, cataplexy, sleep paralysis, and hypnagogic hallucinations, although
30-50 percent of patients with narcolepsy do not have all of these symptoms. Narcoleptic
patients often report disrupted sleep, and polysomnography often confirms fragmented
sleep patterns.
Polysomnography and the multiple sleep latency or maintenance of wakefulness test
performed on patients with narcolepsy typically reveal short sleep latencies. The
polysomnogram may show an early sleep-onset REM episode (i.e. short REM latency).
The multiple sleep latency test typically shows at least two sleep-onset REM periods.
However, up to fifteen percent of patients may not have two sleep-onset REM periods in
a given study.
Polysomnography and a multiple sleep latency test performed on the day after the
polysomnographic evaluation are routinely indicated in the evaluation of suspected
narcolepsy.
IV. Parasomnia and sleep-related epilepsy (ICD-9-CM 307.41-307.49, 780.55,
780.56):
Parasomnias are undesirable physiologic phenomena that occur predominantly during
sleep. These sleep-related events can be injurious to the patient and others and can
produce a serious disruption of sleep-wake schedules and family functioning.
Parasomnias may reflect, or be associated or confused with several diagnoses, including
disorders of arousal from NREM sleep (confusional arousals, sleepwalking, sleep
terrors), REM-sleep behavior disorder, sleep-related epilepsy, and sleep-related
psychiatric disorders.
Epilepsy is a chronic condition characterized by the occurrence of paroxysmal electrical
discharges in the brain and manifested by changes in consciousness, motor control, or
sensory function. Seizures and epilepsy can be categorized into many clinical types and
epileptic syndromes, often requiring different yet specific approaches to diagnosis and
treatment. In 15-20 percent of patients with epilepsy, seizures occur mostly or exclusively
during sleep (sleep-related epilepsy). In the largest reported case series of difficult-to
diagnose paroxysmal nocturnal behaviors, approximately 50 percent of patients were
ultimately diagnosed with sleep-related epilepsy.
INDICATIONS:
1. Polysomnography, including video recording and additional EEG channels in an
extended bilateral montage, is routinely indicated to assist with the diagnosis of
paroxysmal arousals or other sleep disruptions that are thought to be seizure related when
the initial clinical evaluation and results of a standard EEG are inconclusive.
2. Polysomnography is indicated in evaluating sleep-related behaviors that are violent or
otherwise potentially injurious to the patient or others.
3. Polysomnography is indicated when evaluating patients with sleep behaviors
suggestive of parasomnias that are unusual or atypical because of the patient's age at
onset; the time, duration, or frequency of occurrence of the behavior; or the specifics of
the particular motor patterns in question (e.g. stereotypical, repetitive, or focal).
4. Polysomnography may be indicated in situations with forensic considerations (e.g. if
onset follows trauma or if the events themselves have been associated with personal
injury).
5. Polysomnography may be indicated when the presumed parasomnia or sleep-related
epilepsy does not respond to conventional therapy.
6. Polysomnography is not routinely indicated in cases of typical, uncomplicated, and
non-injurious parasomnias when the diagnosis is clearly delineated.
7. Polysomnography is not routinely indicated for patients with epilepsy who have no
specific complaints consistent with a sleep disorder.
V. Restless Legs Syndrome and Periodic Limb Movement Disorder:
Restless legs syndrome is a neurologic disorder characterized by disagreeable leg
sensations that usually occur at rest or before sleep and are alleviated by motor activity.
Periodic limb movements are involuntary, stereotypic, repetitive limb movements that
may occur during sleep and usually involve the legs and, occasionally, the arms. Periodic
limb movements during sleep often accompany restless legs syndrome. Periodic limb
movement disorder is a sleep disorder characterized by periodic limb movements that
cause frequent arousals and lead to insomnia or excessive daytime sleepiness. The results
of polysomnographic studies from patients with severe restless legs syndrome often show
prolonged sleep latencies, decreased sleep efficiency, increased number of awakenings,
significant reductions in total sleep time, and decreased amounts of slow-wave sleep.
Patients with periodic limb movement disorder often have frequent periodic limb
movements that are associated with arousals and awakenings, reduced total sleep time,
and decreased sleep efficiency.
Polysomnography is indicated when a diagnosis of periodic limb movement disorder is
considered because of complaints by the patient or an observer of repetitive limb
movements during sleep and frequent awakenings, fragmented sleep, difficulty
maintaining sleep, or excessive daytime sleepiness.
Polysomnography is not routinely indicated to diagnose or treat restless legs syndrome.
VI. Depression with insomnia:
Depression with insomnia is characterized by the complaint of difficulty with sleep
associated with a psychiatric diagnosis of unipolar or bipolar illness. Difficulty with sleep
maintenance, difficulty with sleep onset, and early morning awakenings may all be
present. Daytime fatigue may also be present, although there is little evidence to suggest
that true physiologic sleepiness is present, except in depression with hypersomnia
(seasonal affective disorder or bipolar depression). During the manic phase of a bipolar
disorder, sleep may be markedly reduced in amount without the patient having a
concurrent complaint of insomnia. Most studies on sleep in depression focus on patients
with unipolar depression or patients in the depressed phase of bipolar illness.
Neither a polysomnogram nor a multiple sleep latency test is routinely indicated in
establishing the diagnosis of depression.
VII. Circadian rhythm sleep disorders:
Circadian rhythm sleep disorders result from a mismatch between an individual's sleep
pattern and the timing and amount of sleep that the person desires, needs, requires, or
expects. The six types of rhythm disorders are time zone change (jet lag) disorder, shift
work disorder, irregular sleep-wake patterns, delayed sleep-phase syndrome, advanced
sleep-phase syndrome, and non-24-hour sleep-wake disorder.
Polysomnography is not routinely indicated for the diagnosis of circadian rhythm sleep
disorders.
VIII. Impotence (ICD-9-CM: 607.84):
Diagnostic nocturnal penile tumescence testing may be covered, under limited
circumstances, to determine whether erectile impotence in men is organic or
psychogenic. Although impotence is not a sleep disorder, the nature of the testing
requires that it be performed during sleep. The tests ordinarily are covered only when
necessary to confirm the treatment to be given (i.e., surgical, medical, or
psychotherapeutic). Ordinarily, a diagnosis may be determined by two nights of
diagnostic testing.
IX. Coverage of Therapeutic Services:
Sleep disorder clinics may at times render therapeutic as well as diagnostic services.
Therapeutic services may be covered in a hospital outpatient setting or in a freestanding
facility provided they meet the pertinent requirements for the particular type of services
and are reasonable and necessary for the patient, and are performed under the direct
personal supervision of a physician.
For a study to be reported as polysomnography, sleep must be recorded and staged.
Clinical Algorithm(s):
Indications for polysomnography based on presenting signs and symptoms are presented
in three algorithms:
1. Evaluation of excessive daytime sleepiness;
2. Evaluation of abnormal behavior or activity during sleep; and
3. Evaluation of snoring.
Coverage Topic
Lab Services
CPT/HCPCS Codes
The following short descriptors are in accordance with the AMA copyright
agreement. Please refer to the current CPT book for full descriptions.
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, SIMULTANEOUS RECORDING OF VENTILATION,
RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN
SATURATION, UNATTENDED BY A TECHNOLOGIST
95807 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION,
RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN
SATURATION, ATTENDED BY A TECHNOLOGIST
95808 POLYSOMNOGRAPHY; SLEEP STAGING WITH 1-3 ADDITIONAL
PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
95810 POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE
ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A
TECHNOLOGIST
95811 POLYSOMNOGRAPHY; 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
95999 UNLISTED NEUROLOGICAL OR NEUROMUSCULAR DIAGNOSTIC
PROCEDURE
ICD-9 Codes that Support Medical Necessity
95805:
347.00 - 347.01
347.10 - 347.11
95807, 95808, 95810:
307.41
TRANSIENT DISORDER OF INITIATING OR MAINTAINING
SLEEP
307.42
PERSISTENT DISORDER OF INITIATING OR MAINTAINING
SLEEP
307.43
TRANSIENT DISORDER OF INITIATING OR MAINTAINING
WAKEFULNESS
307.44
PERSISTENT DISORDER OF INITIATING OR MAINTAINING
WAKEFULNESS
307.45
CIRCADIAN RHYTHM SLEEP DISORDER
307.46
SLEEP AROUSAL DISORDER
307.47
OTHER DYSFUNCTIONS OF SLEEP STAGES OR AROUSAL
FROM SLEEP
307.48
REPETITIVE INTRUSIONS OF SLEEP
307.49
OTHER SPECIFIC DISORDERS OF SLEEP OF NONORGANIC
ORIGIN
347.00 347.01
347.10 347.11
607.84*
IMPOTENCE OF ORGANIC ORIGIN
780.51
INSOMNIA WITH SLEEP APNEA
780.53
HYPERSOMNIA WITH SLEEP APNEA
780.55
DISRUPTIONS OF 24-HOUR SLEEP-WAKE CYCLE
780.56
DYSFUNCTIONS ASSOCIATED WITH SLEEP STAGES OR
AROUSAL FROM SLEEP
780.57
OTHER AND UNSPECIFIED SLEEP APNEA
780.58
SLEEP RELATED MOVEMENT DISORDER
* ICD-9-CM code 607.84 will be allowed with proper documentation establishing
medical necessity.
Documentation Requirements
1. All centers billing sleep studies must maintain proper certification/ accreditation
documentation as defined in the Indications and Limitations.
Examples of appropriate personnel certification is the Registered Polysomnography
Technologist (RPSGT) credentialed through the Board of Registered Polysomnographic
Technologists and somnologist or Diplomate of the ABSM credentialed through the
AASM.
2. The patient is to be evaluated by a physician prior to ordering of test. When billing for
a sleep disorder test, the ordering physician’s UPIN must be indicated on the claim form
and the order kept on record.
3. The center/laboratory must maintain and provide to Medicare upon request sufficient
documentation that the narcolepsy patient is severe enough to interfere with the patients’
well being and health before Medicare benefits are provided for diagnostic testing.
4. If more than two nights of testing are claimed, documentation must accompany the
claims, providing documentation justifying the medical necessity for the additional
test(s).
5. Studies may be performed in a freestanding center that is a direct extension of a
physician’s office or in an Independent Diagnostic Testing Facility (IDTF). Please refer
to policy AC-03-007 for supervision level requirements for services performed in an
IDTF. (This is for Part B services.)