Requirements For Sleep Studies Effective 1/1/2019

Apr. 30, 2019

The Blue Cross and Blue Shield of Montana (BCBSMT) medical policy, “Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome” effective 1/1/2019 contains the BCBSMT criteria for coverage of sleep studies. BCBSMT requires preauthorization for in-lab sleep studies. If the clinical criteria for coverage for an in-lab sleep study is not met, an unattended home sleep study may be an option.

While unattended home sleep studies do not require a preauthorization, there are guidelines in the medical policy that describe the appropriate types of unattended home sleep studies. Unattended home sleep studies may be considered medically necessary in adult patients who have symptoms suggestive of obstructive sleep apnea and must have a minimum of 4 recording channels including:

  • oxygen saturation
  • respiratory movement
  • airflow
  • electrocardiogram (EKG) or heart rate

This type of unattended home sleep study is only represented by CPT® code 95806, Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow and respiratory effort (e.g., thoracoabdominal movement). If other types of unattended home sleep studies are submitted for predetermination or reported on a claim, these services may not meet the BCBSMT medical policy coverage guidelines and may not be covered.

Please review the BCBSMT medical policy “Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome” for complete criteria for coverage of both unattended and attended sleep studies.