Medical Policy Implementation: Polysomnography for Non-Respiratory Sleep Disorders
Effective February 15, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for polysomnography (PSG).
According to the guidelines of our medical policy, Polysomnography for Non-Respiratory Sleep Disorders:
- PSG and a multiple sleep latency test performed on the day after the PSG is considered medically necessary in the evaluation of suspected narcolepsy or idiopathic hypersomnia.
- PSG is considered medically necessary when evaluating members with parasomnias when there is a history of sleep-related injuries or potentially injurious disruptive behaviors.
- PSG is considered medically necessary when a diagnosis of periodic limb movement disorder (PLMD) is considered when there is: (1) A complaint of repetitive limb movement during sleep by the member or an observer AND; (2) No other concurrent sleep disorder AND; (3) At least one of the following is present: frequent awakenings; fragmented sleep; difficulty maintaining sleep; excessive daytime sleepiness.
- PSG for the diagnosis of PLMD is not considered medically necessary when there is concurrent untreated obstructive sleep apnea, restless legs syndrome, narcolepsy or rapid eye movement (REM) sleep behavior disorder.
- PSG is considered investigational for the diagnosis of non‒respiratory sleep disorders not meeting the criteria above, including but not limited to: nightmare disorder, depression, sleep-related bruxism or non-injurious disorders of arousal.
We strongly encourage you to review this entire policy in our online Medical Policy Manual.
Based on the guidelines of our medical policy, Polysomnography for Non-Respiratory Sleep Disorders, AND the submitted diagnosis code CPT® code 95805, claims for services provided on and after February 15, 2016 may be denied as not medically necessary or may pend while information to determine medical appropriateness is requested and reviewed.
Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 15, 2016.
CPT® is a registered mark of the American Medical Association.