PSG and a multiple sleep latency test (MSLT) performed on the day after the PSG may be considered medically necessary in the evaluation of suspected narcolepsy or idiopathic hypersomnia. It is not expected PSG testing would be performed in the member's home.
PSG may be considered medically necessary when evaluating individuals with parasomnias when there is a history of sleep related injurious or potentially injurious disruptive behaviors.
PSG may be considered medically necessary for the diagnosis of periodic limb movement disorder (PLMD) when ALL of the following are criteria met:
- A complaint of repetitive limb movement during sleep by the individual or an observer; and
- No other concurrent sleep disorder; and
- At least ONE of the following is present:
- Frequent awakenings; or
- Fragmented sleep; or
- Difficulty maintaining sleep; or
- Excessive daytime sleepiness.
PSG for the diagnosis of PLMD is considered not medically necessary for the following indications:
- Concurrent untreated obstructive sleep apnea; or
- Restless legs syndrome (RLS); or
- Narcolepsy; or
- REM sleep behavior disorder.
PSG is considered experimental/investigational and therefore non-covered for the diagnosis of non-respiratory sleep disorders not meeting the criteria above. Scientific evidence does not support the use of PSG for non-respiratory sleep disorders.