Prior authorization is not required for Portable/Unattended/Home Sleep Test (HST) for the diagnosis of Obstructive Sleep Apnea (OSA).
Portable/unattended/home sleep test for the diagnosis of OSA is generally covered subject to the indications listed below, and per your plan documents.
Indications that are covered
- Coverage is limited to adults aged 18 or older.
- HST is covered when it is performed in conjunction with a comprehensive sleep evaluation in patients with a high pretest probability of moderate to severe OSA.
- HST is covered for follow-up studies when OSA diagnosis has been established by polysomnography and therapy has been initiated. The intent most often is to evaluate the response to therapy.
- HST must be interpreted by a Sleep Specialist physician (see definition below)
- Coverage of HST is limited to the following devices:
- Type II device (G0398) – Monitors and records a minimum of seven (7) channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory movement/effort and oxygen saturation OR
- Type III device (G0399) – Monitors and records a minimum of four (4) channels: respiratory movement/effort, airflow, ECG/heart rate and oxygen saturation
- Coverage of HST is limited to 1 overnight session, which is considered to be 1 unit of service.
Indications that are not covered
- Type IV HST, code G0400, (e.g. Watch-Pat) is considered experimental and is not covered.
- Home oximetry alone is not considered a valid test for diagnosing OSA and is therefore not covered.
- HST is not covered for any diagnosis in children less than 18 years of age, because it is considered experimental.
- HST is not covered for adults with co-morbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure).
- HST is not covered for adults with suspected sleep disorders other than obstructive sleep apnea (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy) or for screening asymptomatic persons.
- HST billed with a “from” and “to” date or consecutive dates are not covered for more than 1 unit of service.
Obstructive sleep apnea (OSA) refers to apnea syndromes due primarily to collapse of the upper airway during sleep. During sleep, the upper airway becomes occluded, resulting in an episode of apnea. As a result of the apnea, the patient experiences a brief arousal from sleep. With the return of breathing, the patient typically returns to sleep quickly. This sequence is repeated over and over.
Polysomnogram measures bodily functions during sleep and is done in-lab at a sleep center. Some of the measurements taken may include: brain waves, heart rate, nasal and oral breathing, sleep position, and levels of oxygen saturation.
Portable/Unattended/Home Sleep Testing (HST) is done in the home setting or in a health care facility as an unattended sleep study, and provides some of the same measurements as an in-lab sleep study (polysomnogram), such as brain waves, heart rate, nasal and oral breathing, sleep position, and levels of oxygen saturation.
Sleep Specialist is defined as a physician who is Board eligible or certified by the American Board of Sleep Medicine, or a pulmonologist or neurologist whose residency/fellowship included specialized training in sleep disorders and whose practice comprises at least 25% of sleep medicine. (Nurse Practitioners and Physicians Assistants who are directly supervised by a Sleep Specialist physician may also prescribe an HST).
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
95800 - Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory
analysis (eg, by airflow or peripheral arterial tone), and sleep time
95801 - Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation,
and respiratory analysis (eg, by airflow or peripheral arterial tone)
95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory
airflow, and respiratory effort (eg, thoracoabdominal movement)
G0398 - Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7
channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen
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
(this code is not covered, but is included for informational purposes only)
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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.