This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
Effective July 1, 2026, Clinical Coverage Policy 1A-20, Sleep Studies and Polysomnography Services was amended. The amendment includes:
- Signs and symptoms of conditions listed in 3.2.1(a)1 also meet medical necessity requirements for supervised polysomnography or sleep study
- Conditions were added to meet medical necessity requirements for a supervised polysomnography or sleep study as follows:
- Restless Legs Syndrome
- Chronic Insomnia covered when conditions listed in 1.1.1 are met
- Snoring when accompanied by:
- Disturbed sleep patterns;
- Excessive daytime sleepiness;
- Unexplained awake hypercapnia;
- Apneic breathing;
- Cognitive problems; or
- Excessive fatigue.
- A beneficiary with a neuromuscular disorder, coupled with sleep symptoms that have not been diagnosed after assessing sleep history, sleep hygiene and sleep diaries.
- Facility-based sleep study (polysomnography) is covered for diagnosis of obstructive sleep apnea (OSA) if the beneficiary is either unable to operate home equipment or home equipment is unavailable
- Removed prior authorization for unattended (unsupervised) home sleep tests
- Documentation of Clinical Coverage Policy 1A-20 criteria (found in sections 3.1 through 3.4) in the beneficiary record is required.
Refer to Section 8.0 Policy Implementation/Revision Information in Clinical Coverage Policy 1A-20 for a complete list of updates.
Contact
NC Medicaid Contact Center
888-245-0179