Polysomnography (PSG) for Non-Respiratory Sleep Disorders

Section: Diagnostic Medical
Effective Date: July 01, 2018
Revised Date: July 16, 2019
Last Reviewed: May 19, 2020

Description

PSG is a simultaneously monitoring of respiratory, cardiac muscle, brain, and ocular function during sleep. Most often used for diagnosing sleep apnea.

Video recording may also be performed during PSG to assess parasomnias such as rapid eye movement (REM) sleep behavior disorder (RBD).

Criteria

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 patients 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 patient 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.

Procedure Codes 

95782   95783   95805   95808   95810  
95811

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 95782 , 95783, 95808, 95810 and 95811

G47.11 G47.12 G47.50 G47.51 G47.53 G47.54 G47.59
G47.61

Covered Diagnosis Codes for Procedure Codes: 95805

G47.411 G47.419

    

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New Policy

Internal Medical Policy Committee 5-19-2020 Annual Review

Links

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.