Sleep Studies: Polysomnography
Chapter: Medicine: Tests
© Blue Cross and Blue Shield of Montana
Current Effective Date: 05/09/2008
Original Effective Date: 11/01/2001
Revised Dates: Original policy named Sleep Apnea and Sleep Disorders, September 14, 2005, May 9, 2008, March 1, 2010: Title change. MSLT and Home Sleep Studies are now separate policies.
Note: This policy covers the diagnosis of obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) through the use of a variety of tests, predominantly polysomnography. Also, see the medical policies: Obstructive Sleep Apnea: Medical and Non-surgical Treatment; Obstructive Sleep Apnea: Surgical Treatment; Home Sleep Studies, Unattended/Unsupervised; and Multiple Sleep Latency Testing (MSLT).
The "gold standard" diagnostic test for OSA/UARS is a polysomnography performed in a sleep laboratory.
By definition, polysomnography always includes sleep staging, while a "sleep study" does not. Polysomnography, as described by CPT codes 95808, 95810 and 95811 is a complex medical procedure that involves an overnight stay in a specialized facility. The patient is monitored continuously during the night on a polygraph or other recording system, and continuous auditory and video recordings are made. A trained technologist is present throughout the procedure and a physician inspects and interprets the entire recording. Polysomnographs are scored according to an apneic/hypopneic index (AHI). A standard polysomnography required for sleep staging includes:
• Electroencephalogram (EEG) (1 to 4 leads)
• Submental Electromyogram (EMG)
• Electrooculogram (EOG) to detect arousal, REM sleep
Additional parameters of sleep that may be measured include:
• Electromyography (EMG) at the anterior tibialis muscle to assess sleep-associated leg movements
• Respiratory monitoring with inductance plethysmography of the chest (or diaphragmatic or intercostal myography) to determine respiratory excursions
• Electrocardiogram (ECG) for continuous heart rhythm monitoring
• Ear or digit pulse oximetry to measure arterial oxygen saturation or end tidal gas analysis
• Airflow measured via thermistor or pneumotachograph
• Esophageal pH monitoring to detect gastroesophageal reflux
• Esophageal pressure monitoring
• Continuous blood pressure monitoring
• Extended EEG monitoring (more than 4 leads)
• Penile tumescence
• Sleep position
The current practice parameters of the American Academy of Sleep Medicine, define 4 types of monitoring devices:
Type 1: Comprehensive polysomnography
Type 2: Comprehensive portable polysomnography
Type 3: Modified portable sleep apnea testing consisting of 4 channels of monitoring;
Type 4: Continuous single or dual bioparameters, consisting of 1 or 2 channels, typically oxygen saturation, or airflow
Sleep studies my be considered attended or unattended. An attendant ensures the monitors are attached appropriately, can detect sleep positions that aggravate OSA/UARS (such as sleeping in a prone position) and document patterns of snoring. If severe OSA is identified, continuous positive airway pressure (CPAP) therapy can be initiated. This type of study is known as "split-night" study as the diagnosis of OSA is established during the first half of the night and CPAP titration is implemented during the second half. This strategy may eliminate the need for additional an polysomnogram.
A variety of devices have been developed specifically to evaluate OSA at home. Devices typically are not supervised and don't record EEG and are categorized as an unsupervised sleep study according to CPT terminology.
Polysomnography for the following conditions which can be diagnosed through more appropriate means:
• Drug dependency;
• Nocturnal myoclonus;
• Shift work and schedule disturbances;
• Somnambulism (sleep walking);
• Migraine headaches; or
Attended Polysomnography (sleep study)
Prior authorization is NOT recommended for attended sleep studies.
Blue Cross and Blue Shield of Montana (BCBSMT) considers an attended polysomnography (sleep study) performed in a sleep laboratory medically necessary as a diagnostic test of OSA/UARS and as a technique to initiate and titrate CPAP in patients with clinically significant OSA/UARS. Symptoms include, but are not limited to, the following:
• Excessive daytime sleepiness which may be documented on the Epworth Sleepiness Scale7
• Auto accidents related to sleepiness
• Observed apneic episodes
• Hypertension/pulmonary hypertension or CVA (stroke)
To the extent the results are still pertinent, previous testing performed by the attending physician, should not be duplicated. However, more than one polysomnography may be allowed when the following guidelines are met:
• One polysomnography is needed to confirm a diagnosis of obstructive sleep apnea syndrome
• A second polysomnography may be required to adjust the CPAP device
• An additional polysomnograph may be necessary for evaluating treatment response and making subsequent treatment management decisions
Rationale for Benefit Administration
This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.
The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.
When using this policy to determine whether a service, supply, drug or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.
1.Dr. Elizabeth Brown, BCBSA, e-mail of July 16, 2001
2.Sleepnet.com/apnea39/messages, UARS Explained, September 11, 2000
3.National Institute of Home Sleep Studies (NIHSS), nihss.com/valid.html
4.Abstract: Gastroesophageal Reflux in Patients with Sleep Apnea Syndrome, Graf, K. I., Karaus M.,Heinemann S., Korber S., Dorow P., Hampel, K. E., Department of Internal Medicine, Virchow-Klinikum, Humboldt-Universitat, Berlin, Germany, National Library of Medicine (NLM), PubMed, ncbi.nlm.nih.gov/entrez/query
5.Full Polysomnography in the Home, Fry, June M., DiPhillipo Mark A., Durran, Kenneth, Goldberg, Rochelle, and Baran, A. Sinan, Sleep, Volume 21, No. 6, 1998
6.American Sleep Disorders Association (ASDA) Standards of Practice, Practice Parameters for the Use of Portable Recording in the Assessment of Obstructive Sleep Apnea, Board of the ASDA, Sleep, Volume 17, No. 4, 1994, www.ngc.gov.guidelines/ngc_896
7.The Epworth Sleepiness Scale. 12. http://www.sleepdisorderchannel.com/epworth.shtml. last accessed Dec. 13, 2006.
8.The Upper Airway Resistance Syndrome, Exar, E. N., Collop, N. A., Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, South Carolina, Chest, April 1999, 115(4): 1127-39
9.Upper Airway Resistance Syndrome, Nocturnal Blood Pressure Monitoring, and Borderline Hypertension, Guilleminault, C., Stoohs R., Shiomi, T., Kushida, C., and Schnittger, I., Stanford University Sleep Disorders Center, Palo Alto, California, Chest, April 1996, 109(4):901-8
10.Significance and Treatment of Nonapneic Snoring, Strollor, P. J., Jr. and Sanders, M. H., Wilford Hall Medical Center, Lackland Air Force Base, Texas, Sleep, August 1993, 16(5):403-8
11.Sleep Studies in Adults, The Regence Group Medical Policy Manual, Section Medicine, Policy 22, Revised March 15, 2001, www.regence.com/trgmedpol/medicine/med22
12.Sleep Apnea and Breathing Related Sleep Disorders, Blue Cross and Blue Shield of North Carolina Corporate Medical Policy, Policy OTH8138, October 2000
13.Sleep Disorders Diagnosis and Treatment, Blue Cross and Blue Shield of Massachusetts, Policy 293, Reviewed March 2001, www.bcbsma.com/hresources/293
14.Sleep Disorder Studies, Blue Cross and Blue Shield of Tennessee Medical Policy Manual, June 21, 2001, www.bcbst.com/MPManual/sleep_disorder_studies
CPT coding makes a distinction between sleep studies, which by definition do not include EEG monitoring, and polysomnography, which includes EEG monitoring. Polysomnograms usually require attendance by a technologist. There is no CPT code for an "unattended" polysomnography. Sleep studies can either be attended or unattended by a technologist. Home or portable sleep studies usually imply unattended sleep studies.
95807 SLEEP STUDY, ATTENDED
95808 POLYSOMNOGRAPHY, 1-3
95810 POLYSOMNOGRAPHY, 4 OR MORE
95811 POLYSOMNOGRAPHY W/CPAP
CPT only © American Medical Association. All Rights Reserved.
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History of Development