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:

1. Moderate to severe pulmonary disease (e.g., patients on oxygen or regular bronchodilator use) 
2. Neuromuscular disease affecting muscles of respiration 
3. Congestive heart failure 
4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy, parasomnia, or periodic limb     movements of sleep 
5. Other respiratory disorders, impotence, restless legs syndrome 
6. History of stroke 
7. 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: 

1. the American Academy of Sleep Medicine (AASM); 
2. the Accreditation Commission for Health Care (ACHC); or 
3. 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.

Contact

NCTracks Call Center; 800-688-6696 or NCTracksprovider@nctracks.com