HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
M-62-006
Topic:
Polysomnography (PSG) for Non-Respiratory Sleep Disorders
Section:
Diagnostic Medical
Effective Date:
February 11, 2019
Issued Date:
February 11, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

 

Polysomnography (PSG) records multiple physiologic parameters relevent to sleep.

Video recording may also be performed during PSG to assess parasomnias such as rapid eye movement (REM) sleep behavior disorder (RBD).

 

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

PSG and a multiple sleep latency test performed on the day after the PSG may be considered medically necessary in the evaluation of suspected narcolepsy or idiopathic hypersomnia. It is not expected PSG testing would be performed in the member’s home.

PSG may be considered medically necessary when evaluating patients with parasomnias when there is a history of sleep related injurious or potentially injurious disruptive behaviors.

PSG may be considered medically necessary for the diagnosis of periodic limb movement disorder when ALL of the following are criteria met:

  • A complaint of repetitive limb movement during sleep by the patient or an observer; and
  • No other concurrent sleep disorder; and
  • At least ONE of the following is present:
    • Frequent awakenings; or
    • Fragmented sleep; or
    • Difficulty maintaining sleep; or
    • Excessive daytime sleepiness.

PSG for the diagnosis of periodic limb movement disorder is considered not medically when there is concurrent:

  • Untreated obstructive sleep apnea; or
  • Restless legs syndrome (RLS); or
  • Narcolepsy; or
  • REM sleep behavior disorder.

PSG is considered experimental/investigational and therefore non-covered for the diagnosis of non‒respiratory sleep disorders not meeting the criteria above, including but not limited to nighmare disorder, depressio.n, sleep-related bruxism, or noninjurious disorders of arousal
Scientific evidence does not support the use of PSG for non‒respiratory sleep disorders.

95782

95783

95805

95808

95810

95811

 


Professional Statements and Societal Positions Guidelines

American Academy of Sleep Medicine (AASM) 2005 practice parameters indications for PSG and related procedures recommendations for PSG for non-respiratory indications:

  • PSG and a MSLT performed on the day after the PSG are routinely indicated in the evaluation of suspected narcolepsy.
  • PSG is not routinely indicated in cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated.
  • PSG is indicated when evaluating patients with sleep behaviors suggestive of parasomnias that are unusual or atypical because of the patient’s age at onset; the time, duration or frequency of occurrence of the behavior; or the specifics of the particular motor patterns in question.
  • PSG is indicated in the following situations:
    • Evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; or
    • In situations with forensic considerations (e.g., if onset follows trauma or if the events themselves have been associated with personal injury); or
    • When the presumed parasomnia does not respond to conventional therapy.
  • PSG is indicated when a diagnosis of PLMD is considered because of complaints by the patient or an observer of repetitive limb movement during sleep and frequent awakenings, fragmented sleep, difficulty maintaining sleep, or excessive daytime sleepiness.
  • Intra-individual night-to-night variability exists in patients with periodic limb movement sleep disorder and a single study might not be adequate to establish this diagnosis.  
  • PSG is not routinely indicated to diagnose or treat RLS, except where uncertainty exists in the diagnosis.
  • PSG is not routinely indicated for the diagnosis of circadian rhythm sleep disorders.

American Academy of Sleep Medicine (AASM) 2012 published practice parameters for non-respiratory indications for PSG and MSLT in children. The following recommendations are for PSG and MSLT were made:

  • PSG is indicated for children suspected of having PLMD for diagnosing PLMD.
  • The MSLT, preceded by nocturnal PSG, is indicated in children as part of the evaluation for suspected narcolepsy.
  • Children with frequent NREM [non‒rapid eye movement] parasomnias, epilepsy, or nocturnal enuresis should be clinically screened for the presence of comorbid sleep disorders and polysomnography should be performed if there is a suspicion for sleep-disordered breathing or periodic limb movement disorder.
  • The MSLT, preceded by nocturnal PSG, is indicated in children suspected of having hypersomnia from causes other than narcolepsy to assess excessive sleepiness and to aid in differentiation from narcolepsy.
  • The polysomnogram using an expanded EEG montage is indicated in children to confirm the diagnosis of an atypical or potentially injurious parasomnia or differentiate a parasomnia from sleep-related epilepsy.
  • Polysomnography is indicated in children suspected of having  RLS who require supportive data for diagnosing RLS.

Recommendations against PSG use:

PSG is not routinely indicated for evaluation of children with sleep-related bruxism.


Covered Diagnosis Codes for Procedure Codes: 95782 , 95783, 95808, 95810 and 95811

G47.11

G47.12

G47.50

G47.51

G47.53

G47.54

G47.59

G-47.61

 

 

 

 

 

 

 

Covered Diagnosis Codes for Procedure Codes: 95805

G47.411

G47.419

 

 

 

 

 


Place of Service: Outpatient

PSG for non-respiratory sleep disorders is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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    200 Independence Avenue, SW
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    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.