Clinical Policy 1A-20, Sleep Studies and Polysomnography Services Revised Effective May 1, 2021
In preparation for posting Clinical Coverage Policy 1A-20, NC Medicaid:
- Added coverage for 95800, Study of Sleep Patterns, Including Sleep Time, effective 4/1/2021.
- Updated prior authorization criteria to include coverage for a device utilizing Peripheral Arterial Tone (PAT), oximetry and actigraphy for unattended sleep studies, effective 4/1/2021.
- Added Section 3.3 and 3.4 as follows:
3.3 Repeat Polysomnography for Diagnosing Sleep Apnea
Medicaid and NCHC shall cover a repeat polysomnography for diagnosing sleep apnea, when the required documentation to justify the medical necessity for the repeated test is provided, and ONE of the following criteria are met:
a. the first study is technically inadequate due to equipment failure;
b. the beneficiary could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis;
c. the results were inconclusive or ambiguous; or
d. initiation of therapy or confirmation of the efficacy of prescribed therapy is needed.
3.4 Follow-up Polysomnography
Medicaid and NCHC shall cover follow-up polysomnography when ONE of the following criteria are met:
a. 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;
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.
- Added the following medical comorbidities not covered for home sleep tests (HST) in Section 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC:
- Moderate to severe pulmonary disease (e.g., patients on oxygen or regular bronchodilator use)
- Neuromuscular disease affecting muscles of respiration
- Congestive heart failure
- Suspicion of the presence of other sleep disorders, i.e. narcolepsy, parasomnia, or periodic limb movements of sleep
- Other respiratory disorders, impotence, restless legs syndrome
- History of stroke
- Chronic opioid medication use
- Added Section 7.2 Documentation
In order to perform the technical component (TC) of PSG and sleep testing (including HST), the following must be met:
The sleep center or laboratory must maintain documentation on file that indicates it is accredited by either:
- the American Academy of Sleep Medicine (AASM);
- the Accreditation Commission for Health Care (ACHC); or
- the Ambulatory Care Accreditation Program of the Joint Commission;
Providers are encouraged to review Clinical Policy 1A-20, Sleep Studies and Polysomnography Services to familiarize themselves with the updates.
NCTracks Call Center; 800-688-6696 or NCTracksprovider@nctracks.com