Medicare Advantage

Medical Policy

Title:

Home-Based Sleep Studies

Policy #:

MA07.028

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

Home-based sleep testing is considered medically necessary, and therefore, covered to diagnose obstructive sleep apnea (OSA) when the following criteria are met:

The individual has a high pretest probability of moderate to severe OSA.
The testing is performed in conjunction with a comprehensive sleep evaluation performed by a professional provider.
The individual does not have one of the following comorbidities:
- Moderate to severe pulmonary disease
- Neuromuscular disease
- Congestive heart failure
- Other sleep disorders such as central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy

FOLLOW-UP STUDIES
Follow-up home-based sleep studies for individuals with an established diagnosis of OSA are medically necessary and, therefore, covered for the following indications:

After substantial weight loss in individuals using continuous positive airway pressure (CPAP) for treatment to ascertain whether CPAP is still required at the previously ordered titrated pressure.
After substantial weight gain in individuals previously successfully treated with CPAP, who are presently symptomatic despite the continued use of CPAP to ascertain whether pressure adjustments are needed.
When clinical response is insufficient or the individual's symptoms have returned despite a satisfactory initial response to treatment with CPAP.

An individual who undergoes a home-based sleep test must receive, prior to the test, adequate instruction on how to properly apply the portable sleep monitoring device by the professional provider conducting the home-based sleep test by face-to-face demonstration, video, or telephonic instruction and the 24-hour availability of qualified personnel to answer questions or troubleshoot issues with the device.

All data from home sleep studies must be reviewed and interpreted by a professional provider either board-certified in sleep medicine or overseen by a board-certified sleep medicine professional provider.

REQUIRED DOCUMENTATION

The individual’s medical record must reflect sufficient information to support medical necessity for the testing provided such as:

Face-to-face encounter by the treating professional provider
Relevant medical history
Signs and symptoms (e.g., daytime somnolence, witnessed apneic episodes and snoring history, evaluation of sleep/wake times)
Physical examination (e.g., general examination/appearance, vital signs, body mass index).

These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Documentation should indicate that the home-based sleep test was performed using one of the following devices:

Type 2: measuring a minimum of seven channels including EEG, EOG, EMG, EKG/heart rate, airflow, respiratory effort, and oxygen saturation
Type 3: measuring a minimum of four channels including oxygen saturation, respiratory movement, airflow and EKG/heart rate
Type 4: measuring at least three channels with one being airflow

Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, home-based sleep studies are covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary and not covered are not eligible for coverage or reimbursement by the Company

Description

OBSTRUCTIVE SLEEP APNEA

Obstructive sleep apnea (OSA) is the collapse of the oropharyngeal walls and the obstruction of airflow occurring during sleep. The individual may literally stop breathing (apnea) for a short period or have decreased breathing (hypopnea), repeatedly during sleep. The apnea episodes often last for a minute or longer and can occur hundreds of times during a single night’s sleep. During the obstructive apnea episodes, either complete or partial obstruction of the airway occurs. When the airway closes, breathing stops and the individual awakens to open the airway. Arousals from sleep usually last only a few seconds, but these brief arousals disrupt continuous sleep and prevent reaching deep stages of sleep (e.g., rapid eye movement [REM] sleep), which is necessary in order for the body to rest and replenish strength. This cycle is repeated throughout the sleep period.

OSA may be caused by one of the following conditions:

Reduced upper airway caliber due to obesity
Adenotonsillar hypertrophy
Mandibular deficiency
Macroglossia
Upper airway tumor
Excessive pressure across the collapsible segment of the upper airway
Activity of the muscles of the upper airway insufficient to maintain patency

A diagnosis of OSA is established when the home-based sleep test results meet the following criteria:

The apnea-hypopnea index (AHI) or respiratory index (RDI) is greater than or equal to 15 events per hour; or
The AHI is greater than or equal to five and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of a stroke.

The apnea hypopnea index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour. The respiratory disturbance index (RDI) is equal to the average number of respiratory disturbances per hour.

Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.

HOME-BASED SLEEP TESTING

Home-based testing for OSA refers to a sleep study conducted at home using a portable device that monitors breathing patterns, oxygen levels, and sometimes sleep activity to diagnose obstructive sleep apnea (OSA). The testing, an alternative to a facility-based testing, is an unattended multichannel sleep testing or multichannel sleep monitoring furnished in the individual’s home.

References

American Academy of Sleep Medicine (AASM). Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine clinical practice guideline. [AASM Web site]. March 2017. Available at: https://aasm.org/resources/clinicalguidelines/diagnostic-testing-osa.pdf. Accessed February 11, 2025.

American Academy of Sleep Medicine (AASM). Fact sheet for obstructive sleep apnea. [AASM Web site]. 2008. Available at: https://aasm.org/resources/factsheets/sleepapnea.pdf. Accessed February 11, 2025.

Centers for Medicare & Medicaid Services (CMS). Coverage Decision Memorandum for Sleep Testing for Obstructive Sleep Apnea (OSA) 100-3, change request 6543. [CMS web site]. 2009. Available at: https://www.cms.gov/transmittals/downloads/R103NCD.pdf. Accessed February 11, 2025.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 240.4.1. Sleep Testing for Obstructive Sleep Apnea (OSA). [CMS Web site]. 03/03/2009. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&bc=AAAAQAAAAAAA&. Accessed February 11, 2025.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 240.4. Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA). [CMS Web site]. 03/13/2008. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=226&ncdver=3&bc=0. Accessed February 11, 2025.

Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA) CAG-00405N. Coverage Decision Memorandum for Sleep Testing for Obstructive Sleep Apnea (OSA). [CMS Web site]. 03/03/2009. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=227. Accessed February 11, 2025.

Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA) CAG-00093R2. Proposed Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA). [CMS Web site]. 12/14/2007. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=204. Accessed February 11, 2025.

Novitas Solutions. FAQ: Diagnostic Testing for sleep disorders. [Novitas Web site]. Original: 02/06/2020. Revised: 01/08/2024. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid? ontentId=00005016. Accessed February 11, 2025.

Novitas Solutions. Local Coverage Determination (LCD)L35050. Outpatient Sleep Studies. [Novitas Solutions Web site]. Original: 10/01/2015. Revised: 01/01/2021.
Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35050&ver=55&bc=0. Accessed February 11, 2025.

Novitas Solutions. Local Coverage Article A56923. Billing and Coding: Outpatient Sleep Studies. [Novitas Web site]. Original 09/12/2019. Revised: 01/01/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56923&ver=16&bc=0. Accessed February 11, 2025.

Novitas Solutions. Local Coverage Determination (LCD) L36839. Polysomnography and Other Sleep Studies. [Novitas Web site]. Original: 02/16/2017. Revised: 07/27/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36839&ver=21&bc=0. Accessed February 11, 2025.

Novitas Solutions. Local Coverage Article A56903. Billing and Coding: Polysomnography and Other Sleep Studies. [Novitas Web site]. Original: 08/29/2019. Revised: 07/27/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56903&ver=13&bc=0. Accessed February 11, 2025.

Novitas Solutions. Local Coverage Determination (LCD) L33800. Respiratory assist devices. [Novitas Solutions Web site]. Original: 10/01/2015. Revised: 01/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33800&ver=29&bc=0. Accessed February 11, 2025.

Novitas Solutions. Local Coverage Article A52517. Respiratory assist devices. [Novitas Solutions Web site]. Original: 10/01/2015. Revised 08/08/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52517&ver=46&bc=0. Accessed February 11, 2025.

O'Keeffe T, Patterson EJ. Evidence supporting routine polysomnography before bariatric surgery. Obes Surg. 2004;14(1):23-26.

Pittman SD, Ayas NT, MacDonald MM, et al. Using a wrist-worn device based on peripheral arterial tonometry to diagnose obstructive sleep apnea: in-laboratory and ambulatory validation. Sleep. 2004;27(5):923-933.

Quaseem A, Dallas P, Owens DK, et al. Diagnosis of obstructive sleep apnea in adults: A clinical practice guideline from the Amercian College of Physicians. Ann Intern Med. 2014;161(3):210-220.

Ravesloot MJ, Van Maanen JP, Hilgevoord AA, et. al. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol. 2012;269(7):1865-1871.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

95800, 95801, 95806

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.

HCPCS Level II Code Number(s)

G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG,

G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation

G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA07.028:

04/02/2025

The policy has been reviewed and reissued to communicate the Company's continuing position on home-based sleep studies.

07/24/2024	The policy has been reviewed and reissued to communicate the Company's continuing position on Home-Based Sleep Studies.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
06/14/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on Home-Based Sleep Studies.
04/06/2022	The policy has been reviewed and reissued to communicate the Company's continuing position on Home-Based Sleep Studies.
06/16/2021	This policy has been reissued to communicate the Company's continued coverage criteria for home-based sleep studies, which will no longer be managed by AIM Specialty Health® (AIM).
07/18/2020	This policy has been reissued to communicate the Company's continued coverage criteria for home-based sleep studies, which will no longer be managed by AIM Specialty Health® (AIM).

Version Effective Date:

1/1/2024

Version Issued Date: