SLEEP STUDIES (PREAUTHORIZATION REQUIRED)

I.198





I.198 SLEEP STUDIES (PREAUTHORIZATION REQUIRED)


Policy

Interqual Criteria



InterQual Clinical Criteria

Dates

  • Original Effective
    04-15-2015
  • Last Review
    02-05-2025
  • Next Review
    02-09-2026

Description

Obstructive sleep apnea (OSA) syndrome is characterized by repetitive episodes of upper airway obstruction due to the collapse of the upper airway during sleep. Polysomnography and portable sleep monitoring with type 3 monitors (minimum of arterial oxygen saturation, airflow, and respiratory effort) are established methods for diagnosing OSA. Other proposed methods of diagnosing OSA include limited channel home sleep monitors. Conventional medical management of OSA includes weight loss, avoidance of stimulants, body position adjustment, oral appliances, and use of continuous positive airway pressure (CPAP) during sleep. Novel treatments include nasal expiratory positive airway pressure and oral pressure therapy.

 



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Procedure

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Diagnosis

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Codes

      
          Full Description
            Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
      
          Full Description
            Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
      
          Full Description
            Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
      
          Full Description
            Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
      
          Full Description
            Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
      
          Full Description
            Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist




Revisions

02-14-2024

Policy reviewed at Medical Policy Committee meeting on 02/07/2024 – no changes to policy
07-24-2019

Added 95808, which was missing from policy.  This code was in the previous interqual policy.
04-17-2019

Added internal note;

NOTE:

If 95810 or 95811 is approvable, please add both codes to Tbyrd event.