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					                              Local Coverage Determination

CPT Code/Search Topic
95805, 95807, 95808, 95810

LMRP/LCD ID
L12904

LMRP/LCD Title
Diagnostic Testing for Sleep Disorders

          Indications and Limitations of Coverage and/or Medical Necessity

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 95808and 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.


Coverage Topic
Diagnostic Tests and X-Rays
Outpatient Hospital Services

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


 54250 NOCTURNAL PENILE TUMESCENCE AND/OR RIGIDITY TEST
 95805 MULTIPLE SLEEP LATENCY OR MAINTENANCE OF WAKEFULNESS
       TESTING, RECORDING, ANALYSIS AND INTERPRETATION OF
       PHYSIOLOGICAL MEASUREMENTS OF SLEEP DURING MULTIPLE
       TRIALS TO ASSESS SLEEPINESS
 95807 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION,
       RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN
       SATURATION, ATTENDED BY A TECHNOLOGIST
 95808 POLYSOMNOGRAPHY; SLEEP STAGING WITH 1-3 ADDITIONAL
       PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST
 95810 POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE
       ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A
       TECHNOLOGIST
 95822 ELECTROENCEPHALOGRAM (EEG); RECORDING IN COMA OR
       SLEEP ONLY



ICD-9 Codes that Support Medical Necessity
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



 307.46        SLEEP AROUSAL DISORDER
 307.47        OTHER DYSFUNCTIONS OF SLEEP STAGES OR AROUSAL
               FROM SLEEP
 307.48        REPETITIVE INTRUSIONS OF SLEEP
 347.00 -
 347.11
 607.84        IMPOTENCE OF ORGANIC ORIGIN
 780.50        UNSPECIFIED SLEEP DISTURBANCE
 780.51        INSOMNIA WITH SLEEP APNEA
780.53   HYPERSOMNIA WITH SLEEP APNEA
780.54   OTHER HYPERSOMNIA
780.55   DISRUPTIONS OF 24-HOUR SLEEP-WAKE CYCLE
780.56   DYSFUNCTIONS ASSOCIATED WITH SLEEP STAGES OR
         AROUSAL FROM SLEEP
780.57   OTHER AND UNSPECIFIED SLEEP APNEA
780.58   SLEEP RELATED MOVEMENT DISORDER
780.59   OTHER SLEEP DISTURBANCES

				
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