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Coverage criteria policies

Sleep studies – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for in-lab sleep studies/ polysomnograms.

Coverage

Sleep studies include selected diagnostic and therapeutic services provided for sleep-related disorders. In-lab sleep studies or polysomnograms are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. A sleep specialist must administer an in-lab sleep study or polysomnogram.
  2. Sleep studies will be covered for recipients with the following conditions:
    1. Diagnosis of obstructive sleep apnea and other sleep-related breathing disorders
    2. Neuromuscular disorders with sleep-related symptoms that are not adequately diagnosed through:
      1. Sleep history
      2. Assessment of sleep hygiene
      3. Review of sleep diaries
    3. Suspected narcolepsy
    4. Parasomnias (cases of dangerous, violent or injurious behavior, seizure cases with inconclusive EEG, and atypical parasomnias)
    5. Periodic limb movement disorder (PLMD)
  3. Sleep testing must be:
    1. Conducted in a sleep laboratory
    2. Attended by a trained sleep specialist
    3. Conducted following a careful exam and history that includes a standardized questionnaire
  4. Attended in-home (portable) studies will be covered only in cases where the patient is unable to undergo an in-lab study due to circumstances such as:
    1. Nonambulation
    2. Severe and persistent mental illness

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minnesota Health Care Provider Manual - Physician and Professional Services - Sleep Testing (Revised: 07-08-2016)

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Policy activity

  • 11/01/2016 - Date of origin
  • 12/01/2016 - Effective date

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