Medical Policy

Subject: Studies, Medical Policy #: 31.0 Original Effective Date: 01/23/2019 Status: Reviewed Last Review Date: 07/22/2020

Disclaimer

Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy.

Description

Polysomnography (PSG) includes sleep staging, which requires items 1 through 3 below. Polysomnography is defined to minimally include, but is not limited to, the following:

• A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp. • Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye. • A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, and/or masseter regions. • Rhythm electrocardiogram (ECG). • Nasal and/or oral airflow via both thermistor and nasal pressure sensor. • Ventilation and respiratory effort by chest-wall and abdominal movement measured using strain gauges, piezoelectric belts, inductive plethysmography, impedance or inductance pneumography, endoesophageal pressure, or by intercostal EMG • Gas exchange (oxygen saturation [SpO2]) by oximetry, transcutaneous monitoring, or end-tidal gas analysis • Extremity muscle activity, motor activity-movement using EMG • Body positions via mercury switches or by direct observation • Recordings of vibration (frequency or volume) may be recorded • Transcutaneous CO2, esophageal pH, penile trumescence, and bipolar EEG

Total Sleep time - Continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours, (with at least 120 minutes of sleep for the test to be valid), which includes physician review, interpretation and report. The studies are performed to diagnose a variety of sleep disorders and to evaluate a patient’s response to therapies such as continuous (CPAP).

Coverage Determination

Prior Authorization may be required. Logon to Pres Online to submit a request: https://ds.phs.org/preslogin/index.jsp

PHP follows (LCD L35050) guidelines for Outpatient Sleep Studies A. Medical Conditions for Which Testing is Covered Diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed below. 1. The diagnosis of narcolepsy is usually confirmed by an overnight (polysomnography) followed by a multiple sleep latency test (MSLT). The following measurements are normally required to diagnose narcolepsy: • Polysomnographic assessment of the quality and quantity of nighttime sleep; • Determination of the latency of the first REM episode; • MSLT; and • The presence of REM-sleep episodes.

Initial polysomnography and MSLT occasionally fail to identify narcolepsy.

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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Repeat polysomnography may be indicated and is usually facility based: • If the first study is technically inadequate due to equipment failure; • if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; • if the results were inconclusive or ambiguous; OR • if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. 2. Testing by type III or IV devices can also be covered under special circumstances. See definitions of home sleeping testing (HST) section in LCD L35050. Sleep apnea may be due to an occlusion of the airway (obstructive apnea), absence of respiratory effort () or a combination of these factors (mixed sleep apnea). (OSA)- is the collapse of the oropharyngeal walls and the obstruction of airflow occurring during sleep. CMS PUB 100-03 NCD Chapter 1, Section 240.4.1 – Sleep Testing for Obstructive Sleep Apnea (OSA) finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA. OSA may be caused by one of the following: • Reduced upper airway caliber due to obesity; • Adenotonsillar hypertrophy; • Mandibular deficiency; • Macroglossia; • Upper airway tumor; • Excessive pressure across the collapsible segment of the upper airway; • Activity of the muscles of the upper airway insufficient to maintain patency.

Diagnosis of obstructive sleep apnea requires documentation of: • Apnea- Index* (AHI)/Respiratory Disturbance Index (RDI)* greater than or equal to 15 events per hour, OR • AHI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or , or documented hypertension, ischemic disease, or history of stroke.

*For additional information regarding AHI, RDI and the use of continuous positive airway pressure (CPAP), please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 240.4 The use of CPAP devices is covered when ordered and prescribed by the licensed treating physician to be used in adult patients with OSA if either of the AHI/RDI criteria mentioned above are met. See Positive Airway Pressure (PAP) Devices for Treatment of OSA (L33718) or see section below. For DME Positive Airway Pressure Devices for the treatment of Obstructive Sleep Apnea, see MPM 4.3 The polysomnography Type II, III or Type IV devices as defined above must be performed in a facility-based sleep study laboratory or by portable monitoring (including in other parts of a facility, out of facility, or at home testing) under the restrictions listed above and with the credentialing requirements being met. Initial claims must be supported by medical documentation (separate documentation where electronic billing is used) with documentation of medical necessity. The claim must also certify that the documentation supporting a diagnosis of OSA (described above) is available. Split-Night Studies: For patients with severe and unambiguous obstructive sleep apnea, the initiation of treatment with nasal CPAP may be incorporated into the diagnostic study night. This is called a "split-night" study (initial diagnostic polysomnogram followed by CPAP titration during polysomnography on the same night). A split night study is an overnight polysomnogram in which the patient spends the first half of the night being monitored for sleep apnea. In the event the study shows severe enough disease to merit treatment with CPAP (refer to the Medicare DME LCD on CPAP requirements), the technologist will place the patient on CPAP and will adjust the pressure on the CPAP to treat the underlying sleep apnea. This approach may be an alternative to one full night of diagnostic polysomnography followed by a second night of titration as long as: • AHI or RDI as mentioned above • CPAP titration is carried out for more than 3 hours; and Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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• Polysomnography documents that CPAP eliminates or nearly eliminates the respiratory events during REM and NREM sleep.

Repeat polysomnography or sleep testing for diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. Repeat polysomnography/sleep testing may be indicated: • if the first study is technically inadequate due to equipment failure; • if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; • if the results were inconclusive or ambiguous; or • if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed. Follow-up polysomnography or sleep studies are not routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP treatment. Follow-up polysomnography studies may be indicated, however, for the following conditions: • After substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure; • 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 • When clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP. 3. Impotence Refer to CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70 for coverage guidance. 4. These studies shall not be performed in the home. are a group of conditions that represent undesirable or unpleasant occurrences during sleep. Behavior during these times can often lead to damage to the surroundings and injury to the patient or to others. Parasomnia may include conditions such as , sleep terrors, and rapid eye movement (REM) sleep behavior disorders. In many of these cases, the nature of these conditions may be established by careful clinical evaluation. Suspected seizure disorders as possible cause of the parasomnia are appropriately evaluated by standard or prolonged sleep EEG studies. In cases where seizure disorders have been ruled out and in cases that present a history of repeated violent or injurious episodes during sleep, polysomnography may be useful in providing a diagnostic classification or prognosis. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70). Normally, a clinical history, neurologic examination, and routine EEG obtained while the patient is awake and asleep are often sufficient to establish the diagnosis and permit the appropriate treatment of sleep- related epilepsy. In addition, common, uncomplicated, non-injurious parasomnias, such as typical disorders of , , enuresis, somniloquy, and can usually be diagnosed by clinical evaluation alone. Polysomnography is indicated to provide a diagnostic classification or prognosis when both of the following exist: ▪ When the clinical evaluation and results of standard EEG have ruled out a seizure disorder; and ▪ In cases that present a history of episodes during sleep that result in harm to the patient or others.

When polysomnography is performed for the diagnosis of parasomnias, the following measurements are obtained:

▪ Sleep-scoring channels (EEG, EOG, chin EMG); ▪ EEG using an expanded bilateral montage; ▪ EMG for body movements; ▪ Audiovisual recording; and ▪ Documented technologist observations.

B. Coverage of Therapeutic Services. 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

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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patient and are performed under the direct supervision of a physician. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).

Home Sleep Test (HST)

Out of Center Sleep Testing (OCST) - prior terms include Home Sleep Testing (HST), Portable Monitoring (PM) or Out of the Facility (OOF) Testing When the diagnostic evaluation of sleep disorders 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., the 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. See LCD L35050 for complete information on specific requirements for OCST, such as documentation, staffing and facility based or freestanding center etc. OCST is not appropriate for the diagnosis of OSA in patients with significant comorbid medical conditions or comorbid sleep disorders that may degrade the accuracy of PM, including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure. • For patients unable to be studied in the sleep laboratory when such a study is not possible by virtue of immobility, safety, or critical illness. • For follow-up studies when diagnosis has been established by standard polysomnography and therapy and there is a material change in patients’ symptoms or complaints, again in the patient with no comorbid conditions. May also be indicated to monitor the response to non-CPAP treatments for sleep apnea. • When initiation of treatment is urgent and standard polysomnography is not readily available. All OCST apparatus requires adequate and proper education to the patient and must be documented in the medical record, and available upon request. While a face to face meeting is not required, the education must be appropriate. If the patient does not seem to understand the instructions, a face to face meeting should be scheduled. A follow-up visit to review test results should be performed for all patients undergoing OCST in the sleep facility authorized to order such testing or oversee OCST testing. Negative or technically inadequate OCST in patients with a high pretest probability of moderate to severe OSA should have prompt in-laboratory polysomnography. Neither in facility polysomnography nor OCST testing is a covered service for Medicare beneficiaries for general screening of asymptomatic populations. All reasonable and necessary diagnostic tests given for the medical conditions listed above are covered if the criteria are met. At a minimum, OCST must record airflow, respiratory effort, and blood oxygenation. The airflow, effort, and oximetric biosensors conventionally used for in-laboratory PSG should be used in OCST. See above descriptions of monitor types. WatchPAT 100 or WatchPAT 200 device was listed as a covered device by the FDM meeting the criteria for recording of heart rate, oxygen saturation and respiratory analysis (e.g., by airflow or peripheral arterial tone). This device was initially placed in the Type IV monitoring device category but was moved to a special category by CMS. This technology is considered for coverage in this LCD. Our review found that was not a sufficiently accurate substitute measure of sleep time to recommend its routine use. This device can be used for documentation of coverage of CPAP by NCD, but the coverage of interpretation will not be paid separately for reason already stated

CPAP for Treatment of Obstructive Sleep Apnea

Positive Airway Pressure (PAP) Devices for Treatment of Obstructive Sleep Apnea (OSA):

PHP follows CMS LCD (L33718) Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea. LCD L33718 contains criteria for CPAP and BiPAP coverage, as well as information on the sleep tests required to qualify for a respiratory assist device, requirements for continuing coverage of CPAP/BiPAP and physician qualifications.

Initial Coverage: In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea. I. An E0601 CPAP device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A–C are met: A. The member has a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the member for obstructive sleep apnea. B. The member has a sleep test (as defined below) that meets either of the following criteria (1 or 2): 1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or b. b. Hypertension, ischemic heart disease, or history of stroke. C. The member and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment. II. Code E0470 RAD device is covered for those members with OSA who meet criteria A-C above, in addition to criterion D below: D. CPAP (E0601) has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting. Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).

If E0470 is billed for a member with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.

A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary.

If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test.

If an E0601 device has been used for more than 3 months and the beneficiary is switched to an E0470, a new initial face-to- face clinical evaluation is required, but a new sleep test is not required. A new 3-month trial would begin for use of the E0470.

Coverage, coding and documentation requirements for the use of E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) L33800 and related Policy Article (PA).

Definitions Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30 percent reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4 percent oxygen desaturation. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 240.4 [Rev.96, 10-15-2008]).

Multiple sleep Latency testing (MSLT) – MSLT objectively assesses sleep tendency to determine the tendency of the patient to fall asleep. Conversely, the maintenance of wakefulness test (MWT) requires the patient to try to stay awake. MSLT is the better test for showing the sleep-onset REM periods, a determination that is important in establishing the diagnosis of narcolepsy. To insure validity, proper interpretation of the MSLT can only be made following a polysomnography performed on the preceding night.

Out of Center Sleep Testing (OCST), includes other terms Home Sleep Testing (HST), Portable Monitoring (PM) or Out of the Facility (OOF) Testing. Please refer to LCD L35050 Outpatient Sleep Studies for complete information.

Exclusions Polysomnography for Chronic Insomnia Is Not Covered.

The use of polysomnography for diagnosis of patients with chronic insomnia is not covered under Medicare because it is not reasonable and necessary under §1862(a)(1)(A) of the Act.

Repeat of previous sleep test: See CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70 and CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 240.4 for complete information on coverage limitations.

Diagnostic testing that is duplicative of previous sleep testing done by the attending physician to the extent that the previous results are still pertinent is not covered, because it is not reasonable and necessary if there have been no significant clinical changes in the patient's medical history since the previous study.

Polysomnography or sleep studies, and MSLT are not covered in the following situations: • Polysomnography for the diagnosis of patients with chronic insomnia (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70); • To preoperatively evaluate a patient for laser-assisted uvulopalatopharyngoplasty without clinical evidence that obstructive sleep apnea is suspected;

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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• To diagnose chronic lung disease (nocturnal hypoxemia in patients with chronic, obstructive, restrictive or reactive lung disease is usually adequately evaluated by oximetry; however, if the patient's sign/symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography may be considered medically necessary); • In cases where seizure disorders have not been ruled out; • In cases of typical, uncomplicated and non-injurious parasomnias when the diagnosis is clearly delineated; • For patients with epilepsy who have no specific complaints consistent with a sleep disorder; • For patients with symptoms suggestive of periodic limb movement disorder or restless leg syndrome unless symptoms are suspected of being related to a covered indication; • For the diagnosis of insomnia related to depression; • For the diagnosis of sleep disorders (i.e., rapid time-zone change [], shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24-hour sleep/wake disorder).

Inappropriate use of OCST for diagnosis of OSA

OCST is not suitable for diagnosing OSA in patients with significant comorbid medical conditions or comorbid sleep disorders that may degrade the accuracy of Portable Monitoring, including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure.

• For patients unable to be studied in the sleep laboratory when such a study is not possible by virtue of immobility, safety, or critical illness. • For follow-up studies when diagnosis has been established by standard polysomnography and therapy and there is a material change in patients’ symptoms or complaints, again in the patient with no comorbid conditions. May also be indicated to monitor the response to non-CPAP treatments for sleep apnea. • When initiation of treatment is urgent and standard polysomnography is not readily available.

Documentation Requirements 1. All documentation must support the medical necessity of the service and maintained in the patient's medical record and made available upon request. The record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). Legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient must be included. 2. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Certification/ Accreditation 3. All centers billing sleep studies must maintain proper certification/accreditation documentation as defined in the Indications and Limitations, which include: • Accreditation of sleep centers to include—AASM, Joint Commission, or ACHC 4. All Sleep Studies, whether in a facility based, or OCST shall be interpreted by appropriate physician with training in this area. Acceptable Board Certifications include physicians need to be board certified OR board eligible with a certification in Sleep 5. Appropriate technical personnel credentialing includes: • Board of Registered Polysomnographic Technologist (BRPT): o Certified Polysomnographic Technician (CPSGT), o Registered Polysomnography Technologist (RPSGT), and • National Board of Respiratory Care (NBRC): o Certified -Sleep Disorders Specialist (CRT-SDS) o Registered Respiratory Therapist – Sleep Disorders Specialist (RRT-SDS), and • American Board of (ABSM) o Registered Sleep Technologist (RST) 6. The patient is to be evaluated by a physician prior to ordering of test. This physician is not required to be a Sleep Specialist when billing for an OCST. When billing for a sleep disorder test, the ordering physician's national identification number must be indicated on the claim form and the order kept on record. 7. The center/laboratory must maintain and provide upon request sufficient documentation that the narcolepsy patient is severe enough to interfere with the patients' well-being and health before benefits are provided for diagnostic testing. 8. If more than two nights of testing are claimed, medical documentation must justify the medical necessity for the additional test(s) should it be requested. 9. 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) (L35448) with restrictions as indicated in LCD L35050. 10. Sleep studies performed in the home shall only be covered under special circumstances described in Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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LCD L35050 under "Out of Center Sleep Testing (OCST)." All home sleep studies, to be covered, must be under the supervision of the hospital-based sleep lab, a sleep clinic that is a direct extension of the physician's office, an IDTF, or entity accredited by AASM as an OCST entity.

Coding

The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.

Current Procedural Terminology (CPT) Codes CPT Codes Description Polysomnography; younger than 6 years, sleep staging with 4 or more 95782 additional parameters of sleep, attended by a technologist Polysomnography; younger than 6 years, sleep staging with 4 or more 95783 additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist Sleep study, unattended, simultaneous recording; heart rate, oxygen 95800 saturation, respiratory analysis, and sleep time Sleep study, unattended, simultaneous recording; minimum of heart rate, 95801 oxygen saturation, and respiratory analysis Multiple sleep latency or maintenance of wakefulness testing, recording, 95805 analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness Sleep study, unattended, simultaneous recording of, heart rate, oxygen 95806 saturation, respiratory airflow, and respiratory effort Sleep study, simultaneous recording of ventilation, respiratory effort, ECG 95807 or heart rate, and oxygen saturation, attended by a technologist Polysomnography; any age, sleep staging with 1-3 additional parameters 95808 of sleep, attended by a technologist Polysomnography; age 6 years or older, sleep staging with 4 or more 95810 additional parameters of sleep, attended by a technologist Polysomnography; age 6 years or older, sleep staging with 4 or more 95811 additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist G0398 Home sleep study test (HST) with type II portable G0399 Home sleep study test (HST) with type III portable Home sleep study test (HST) with type IV portable monitor, unattended; G0400 minimum of 3 channels

HCPCS Codes Description Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device). • Not reasonable and necessary if the primary diagnosis is OSA. If diagnosis other than OSA see LCD for RAD (L33800) • If an E0601 device is tried and found ineffective during the initial E0470 facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test. • If an E0601 device has been used for more than 3 months and the beneficiary is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not required.

E0601 Continuous positive airway pressure (CPAP) device

ICD-10 Diagnosis Codes ICD-10 Codes Diagnosis for CPT code 95805 E66.2 Morbid (severe) obesity with alveolar hypoventilation

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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ICD-10 Codes Diagnosis for CPT code 95805 F11.182 Opioid abuse with opioid-induced sleep disorder F11.282 Opioid dependence with opioid-induced sleep disorder F11.982 Opioid use, unspecified with opioid-induced sleep disorder Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic- F13.182 induced sleep disorder Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or F13.282 anxiolytic-induced sleep disorder Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or F13.982 anxiolytic-induced sleep disorder F14.182 Cocaine abuse with cocaine-induced sleep disorder F14.282 Cocaine dependence with cocaine-induced sleep disorder F14.982 Cocaine use, unspecified with cocaine-induced sleep disorder F15.182 Other stimulant abuse with stimulant-induced sleep disorder F15.282 Other stimulant dependence with stimulant-induced sleep disorder F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder Other psychoactive substance abuse with psychoactive substance-induced F19.182 sleep disorder Other psychoactive substance dependence with psychoactive substance- F19.282 induced sleep disorder Other psychoactive substance use, unspecified with psychoactive F19.982 substance-induced sleep disorder F51.13 due to other mental disorder Other sleep disorders not due to a substance or known physiological F51.8 condition G47.10 Hypersomnia, unspecified G47.11 with long sleep time G47.12 Idiopathic hypersomnia without long sleep time G47.13 Recurrent hypersomnia Hypersomnia due to medical condition (code also associated medical G47.14 condition) G47.19 Other hypersomnia G47.21 Circadian rhythm sleep disorder, delayed sleep phase type G47.22 Circadian rhythm sleep disorder, advanced sleep phase type G47.23 Circadian rhythm sleep disorder, irregular sleep wake type G47.24 Circadian rhythm sleep disorder, free running type G47.25 Circadian rhythm sleep disorder, jet lag type G47.26 Circadian rhythm sleep disorder, shift work type G47.27 Circadian rhythm sleep disorder in conditions classified elsewhere G47.29 Other circadian rhythm sleep disorder G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.39 Other sleep apnea G47.411 Narcolepsy with G47.419 Narcolepsy without cataplexy Narcolepsy in conditions classified elsewhere with cataplexy (code first G47.421 underlying condition) Narcolepsy in conditions classified elsewhere without cataplexy (code first G47.429 underlying condition) G47.52 REM sleep behavior disorder G47.53 Recurrent isolated

Diagnosis coverage for CPT codes 95800, 95801, 95806, 95807, 95808, ICD-10 CODE 95810, 95811, G0398, G0399, and G0400 E66.2 Morbid (severe) obesity with alveolar hypoventilation F10.182 Alcohol abuse with alcohol-induced sleep disorder F10.282 Alcohol dependence with alcohol-induced sleep disorder F10.982 Alcohol use, unspecified with alcohol-induced sleep disorder F11.182 Opioid abuse with opioid-induced sleep disorder F11.282 Opioid dependence with opioid-induced sleep disorder F11.982 Opioid use, unspecified with opioid-induced sleep disorder Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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Diagnosis coverage for CPT codes 95800, 95801, 95806, 95807, 95808, ICD-10 CODE 95810, 95811, G0398, G0399, and G0400 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic- F13.182 induced sleep disorder Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or F13.282 anxiolytic-induced sleep disorder Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or F13.982 anxiolytic-induced sleep disorder F14.182 Cocaine abuse with cocaine-induced sleep disorder F14.282 Cocaine dependence with cocaine-induced sleep disorder F14.982 Cocaine use, unspecified with cocaine-induced sleep disorder F15.182 Other stimulant abuse with stimulant-induced sleep disorder F15.282 Other stimulant dependence with stimulant-induced sleep disorder F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder Other psychoactive substance abuse with psychoactive substance-induced F19.182 sleep disorder F19.21 Other psychoactive substance dependence, in remission Other psychoactive substance dependence with psychoactive substance- F19.282 induced sleep disorder Other psychoactive substance use, unspecified with psychoactive F19.982 substance-induced sleep disorder F51.01 Primary insomnia F51.02 Adjustment insomnia F51.03 Paradoxical insomnia F51.09 Other insomnia not due to a substance or known physiological condition F51.11 Primary hypersomnia F51.12 Insufficient sleep syndrome Other hypersomnia not due to a substance or known physiological F51.19 condition F51.3 Sleepwalking [somnambulism] F51.4 Sleep terrors [night terrors] F51.5 disorder Other sleep disorders not due to a substance or known physiological F51.8 condition G47.10 Hypersomnia, unspecified G47.11 Idiopathic hypersomnia with long sleep time G47.12 Idiopathic hypersomnia without long sleep time G47.13 Recurrent hypersomnia G47.19 Other hypersomnia G47.20 Circadian rhythm sleep disorder, unspecified type G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.32 High altitude periodic breathing G47.33 Obstructive sleep apnea (adult) (pediatric) G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation G47.35 Congenital central alveolar hypoventilation syndrome G47.36 Sleep related hypoventilation in conditions classified elsewhere G47.39 Other sleep apnea G47.411 Narcolepsy with cataplexy G47.419 Narcolepsy without cataplexy G47.421 Narcolepsy in conditions classified elsewhere with cataplexy G47.429 Narcolepsy in conditions classified elsewhere without cataplexy G47.50 Parasomnia, unspecified G47.51 Confusional G47.54 Parasomnia in conditions classified elsewhere G47.59 Other parasomnia G47.61 Periodic limb movement disorder G47.69 Other sleep related movement disorders G47.8 Other sleep disorders N52.01* Erectile dysfunction due to arterial insufficiency N52.02* Corporo-venous occlusive erectile dysfunction

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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Diagnosis coverage for CPT codes 95800, 95801, 95806, 95807, 95808, ICD-10 CODE 95810, 95811, G0398, G0399, and G0400 Combined arterial insufficiency and corporo-venous occlusive erectile N52.03* dysfunction N52.1* Erectile dysfunction due to diseases classified elsewhere N52.2* Drug-induced erectile dysfunction N52.31* Erectile dysfunction following radical prostatectomy N52.32* Erectile dysfunction following radical cystectomy N52.33* Erectile dysfunction following urethral surgery N52.34* Erectile dysfunction following simple prostatectomy N52.35* Erectile dysfunction following radiation therapy N52.36* Erectile dysfunction following interstitial seed therapy N52.37* Erectile dysfunction following prostate ablative therapy N52.39* Other and unspecified postprocedural erectile dysfunction N52.8* Other male erectile dysfunction N52.9* Male erectile dysfunction, unspecified *ICD-10-CM codes N52.01, N52.02, N52.03, N52.1, N52.2, N52.31, N52.32, N52.33, N52.34, N52.35, N52.36, N52.37, N52.39, N52.8, and N52.9 require proper documentation establishing medical necessity.

Reviewed by / Approval Signatures

Clinical Quality & Utilization Mgmt. Committee: Howard Epstein MD Senior Medical Director: Norman White MD Date Approved: 07/22/2020

References

1. CMS, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, 70 – Sleep Disorder Clinics, Revision #259 on 07-12-19. For additional information on MSLT, Impotence, Parasomnia, Chronic Insomnia and Coverage of Therapeutic Services. Accessed 02-04-2020 2. CMS, Local Coverage Determination LCD L35050, Outpatient Sleep Studies, (Part A/B) Revision number 7, Revision Date 09-12-2019. Assessed 07-23-20 3. CMS, Local Coverage Article: Billing and Coding: Outpatient Sleep Studies (A56923), Effective Date 09-12-2019. Accessed 02-04-2020 4. CMS, Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Section 240.4 ) Coverage Determinations, Revision 198, 06-29-17. For additional info on Sleep Apnea. Accessed 07/23/2020 5. CMS, NCD for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (240.4), Effective Date 03/13/2008. Accessed 07/23/20 6. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70, Sleep Disorder Clinics, (Rev. 1, 10-01-03), [Cited 07-23-2020]. 7. CMS, Local Coverage Determination (LCD), Independent Diagnostic Testing Facility (IDTF) (L35448), Revision Date: 09-26-2019, R16. [Cited 07-23-2020] 8. CMS, Local Coverage Determination, Wisconsin Physicians Service Insurance, (LCD) L36839, Polysomnography and Other Sleep Studies, (Part A), Revision Date: 11/01/2019, R7; Related Article A56903, Revision Date 11/01/2019, R1. [Cited 07/23/2020] 9. CMS, Local Coverage Determination (LCD), Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718), Revision date: 01/01/2020, R#7. Related Policy Article (A52467), Revision date 04-03-2020, R#11. Cited 07/23/2020 10. CMS, Local Coverage Determination (LCD), Respiratory Assist Devices (L33800), Revision History 01/01/2020, R#7. Related Article A52517, Revision History Date: 04/03/2020, R#11 [Cited 07/23/2020]

Publication History

01-23-19 Policy Effective date and was approved by CQUMC 07-22-20 Annual review. There has been no coverage change, only policy format. Will continue with no Prior Authorization of the listed codes. PHP Medical Policy Committee will revisit this policy in near future.

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policy is not a treatment guide and should not be used as such. Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: Click here for Medical Policies

Web links: At any time during your visit to this policy and find the source material web links has been updated, retired or superseded, PHP is not responsible for the continued viability of websites listed in this policy.

When PHP follows a particular guideline such as LCDs, NCDs, MCG, NCCN etc., for the purposes of determining coverage; it is expected providers maintain or have access to appropriate documentation when requested to support coverage. See the References section to view the source materials used to develop this resource document.

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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