Highmark Medicare Services

00363

FISCAL INTERMEDIARY

L12904

Diagnostic Testing For Sleep Disorders

05-058

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Pennsylvania

Region III

For services performed on or after 06/20/2003

For services performed on or after 10/01/2005

02/14/2006

Diagnostic testing is performed to diagnose sleep disorders, to diagnose selected cases of impotence, and to evaluate a patient’s response to possible therapies. Sleep studies are continuous and simultaneous monitoring and recording of various parameters of sleep for 6 or more hours with physician review, interpretation and report.

Polysomnography (PSG) differs from sleep studies, because it includes sleep staging, and requires the use of a 1-4 lead electroencephalogram (EEG), an electrooculogram (EOG), and a submental electromyogram (EMG). Other PSG tests may include but are not limited to: electrocardiogram (ECG); nasal and/or oral airflow, ventilation and respiratory effort; gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis; extremity muscle activity, motor activity movement; extended EEG monitoring; penile tumescence; gastroesophageal reflux; continuous blood pressure monitoring; snoring; body positions.

The Multiple Sleep Latency Test (MSLT) is a standardized measure of physiologic sleepiness. The same parameters as for basic polysomnography are monitored-two eye movements and two EEG channels, EKG, airflow, and submental EMG. The MSLT consists of twenty-minute nap opportunities offered at two-hour intervals. To insure validity, proper interpretation of the MSLT can only be made following a PSG performed on the preceding night.

This LCD will only address diagnostic testing, not therapeutic interventions for sleep disorders. Further, this LCD will not address diagnostic testing related to Continuous Positive Airway Pressure (CPAP). Providers should review the National Coverage Decision (NCD) regarding CPAP and the Durable Medical Equipment Carrier (DMERC) coverage decision on this topic.

Diagnostic testing for sleep disorders may be indicated when the patient's symptoms of sleep disturbance are severe enough to interfere with the patient's ability to function and are not explained by other medical conditions or medications.

Symptoms of significant sleep disorders may include but are not limited to:

-inappropriate sleep episodes or attacks (e.g., while driving, in the middle of a meal, in the middle of a conversation)

-episodes of amnesia

-continuous disabling drowsiness or excessive daytime sleepiness (EDS)

-cataplexy (a condition in which there are abrupt attacks of muscular weakness and hypotonia triggered by an emotional stimulus such as mirth, anger, fear or surprise)

-sleep paralysis (experience of being awake but unable to move usually occurring near sleep onset or offset lasting a few seconds)

-hypnogogic hallucinations (vivid dream like experiences which the patient cannot distinguish from reality)

-cessation or near cessation of respiration

-snoring

-abnormal motor activity during sleep (e.g., patients flail out and throw the bedcovers off and may sit up or get out of bed)

-nocturia

-cognitive impairment, including poor memory and personality changes related to sleep disruption.

Additionally, sleep disorder testing may be indicated:

-to evaluate the response to treatment (e.g., oral appliances, surgical intervention)

-in the evaluation of selected patients with impotence

-to assist with the diagnosis of selected patients with paroxysmal arousals or other sleep disruptions that are thought to be seizure related

-to assist with the diagnosis of other parasomnias ( behavior disorders during sleep that are associated with brief or partial arousals).

Diagnostic testing for sleep disorders using polysomnography is not indicated for chronic insomnia.

Unattended sleep studies are not indicated.

Sleep Disorder Tests

1. Nocturnal penile tumescence and/or rigidity test (CPT code 54250)

This test may be indicated in the evaluation of selected patients with impotence.

Although impotence is not a sleep disorder, the nature of the testing requires that it be performed during sleep. Testing may be indicated to confirm the treatment to be given (surgical, medical or psychotherapeutic). Ordinarily, a diagnosis may be determined by two nights of diagnostic testing. Diagnostic testing that duplicates previous testing is not covered.

2. Multiple sleep latency test, MSLT (CPT code 95805)

This test may be indicated to assist in confirming a diagnosis of narcolepsy. A MSLT is not routinely indicated for most patients with sleep-related breathing disorders.

3. Sleep study (CPT code 95807)

This test may be indicated :

-to evaluate the response to treatment (e.g., oral appliances, surgical intervention)

4. Polysomnography (PSG) (CPT codes 95808 and 95810, only)

These tests may be indicated to assist in confirming the diagnoses of narcolepsy and/or sleep apnea. PSG may be indicated for:

-inappropriate sleep episodes or attacks (e.g., while driving, in the middle of a meal in the middle of a conversation)

-episodes of amnesia

-continuous disabling drowsiness or excessive daytime sleepiness

-cataplexy

-sleep paralysis

-hypnogogic hallucinations

-cessation or near cessation of respiration

-snoring

-abnormal motor activity

-nocturia

-cognitive impairment, including poor memory and personality changes related to sleep disruption

Additionally, PSG testing may also be indicated to evaluate a patient's response to treatment (e.g., oral appliances, surgical intervention).

When an initial clinical evaluation and standard EEG are inconclusive, polysomnography, with video recording and additional EEG channels, may be indicated:

-to assist with the diagnosis of paroxysmal arousals;

-to assist in the diagnosis of other sleep disruptions that are thought to be seizure related;

-to assist with the diagnosis of other parasomnias.

Polysomnography is not routinely indicated for patients with epilepsy who have no specific complaints consistent with a sleep disorder.

5. Electroencephalogram (EEG), sleep only (CPT code 95822)

This test may be indicated to assist in the diagnoses of narcolepsy and/or sleep apnea. It may also be indicated to assist in the diagnosis of paroxysmal arousals, other sleep disruptions that are thought to be seizure related, and other parasomnias, when the initial clinical evaluation and standard EEG are inconclusive.

Sleep EEG is not routinely indicated for patients with epilepsy who have no specific complaints consistent with a sleep disorder.

Diagnostic Tests and X-Rays Outpatient Hospital Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Note:
Regarding morbid obesity, ICD-9-CM codes 278.01 and 278.8, while it is permissible to have these codes on the claim, they are insufficient when used alone. Please refer to the listing of diagnoses in this section.

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Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

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05-058

11/11/2005