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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored

Service Code
95711 (CPT) Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG)

Service Code
95718 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpret

Service Code
95720 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpret
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60

Service Code
95721 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60

Service Code
95722 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84

Service Code
95723 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84

Service Code
95724 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG re

Service Code
95725 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG re
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG re

Service Code
95726 (CPT) Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG re
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Sleep Studies and Polysomnography Services

Service Code
95782 (CPT) Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

For participating providers, no pre-authorization is required for members under 18 years old. For all other members, pre-authorization is required for all providers.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

Sleep Studies and Polysomnography Services

Service Code
95783 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

For participating providers, no pre-authorization is required for members under 18 years old. For all other members, pre-authorization is required for all providers.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

Sleep Studies and Polysomnography Services

Service Code
95800 (CPT) Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)

Service Code
95803 (CPT) Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Sleep Studies and Polysomnography Services

Service Code
95805 (CPT) Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

N/A - No authorization is required

Resources

Sleep Studies and Polysomnography Services

Service Code
95806 (CPT) Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Sleep Studies and Polysomnography Services

Service Code
95807 (CPT) Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

For participating providers, no pre-authorization is required for members under 18 years old. For all other members, pre-authorization is required for all providers.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

Sleep Studies and Polysomnography Services

Service Code
95808 (CPT) Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

For participating providers, no pre-authorization is required for members under 18 years old. For all other members, pre-authorization is required for all providers.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

Sleep Studies and Polysomnography Services

Service Code
95810 (CPT) Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

For participating providers, no pre-authorization is required for members under 18 years old. For all other members, pre-authorization is required for all providers.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

Sleep Studies and Polysomnography Services

Service Code
95811 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Polysomnography (PSG) and sleep studies are used to diagnose sleep disorders and record nighttime sleep patterns. Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. Polysomnography records brain waves, oxygen levels in the blood, heart rate, breathing, eye and leg movements during the study. Polysomnography may be used to evaluate a beneficiary’s response to therapies such as continuous positive airway pressure (CPAP). Polysomnography is usually done at a sleep disorders unit within a hospital or a sleep center. Polysomnography is occasionally done during the day to accommodate shift workers who habitually sleep during the day.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

For participating providers, no pre-authorization is required for members under 18 years old. For all other members, pre-authorization is required for all providers.

Limits

Previous testing performed by the attending physician, to the extent the results are still pertinent, must not be duplicated. Sleep studies and polysomnography must consist of recording, interpretation, and reporting.

Exclusions

Medicaid shall not cover sleep studies and polysomnography for the following indications:

  • 1. Impotence.
  • 2. Chronic insomnia, except when an underlying physiology exists, such as

those listed under Subsection 3.2.1.

  • 3. Snoring, except when an underlying physiology exists, such as

conditions listed in 3.2.1.a.1.F.:b. Medicaid shall not cover Unattended Sleep Studies or Home Sleep Tests (HST) for the following indications:

  • 1. For a beneficiary who is considered at low to moderate risk for OSA; or
  • 2. After a negative, inconclusive, or technically inadequate HST; or
  • 3. For a beneficiary under 18 years of age.

HST is not covered for a beneficiary with certain medical comorbidities, including:

  • 1. Moderate to severe pulmonary disease (e.g., a beneficiary on oxygen or

regular bronchodilator use);

  • 2. Neuromuscular disease affecting muscles of respiration;
  • 3. Congestive heart failure;
  • 4. Suspicion of the presence of other sleep disorders, i.e. narcolepsy,

parasomnia, or periodic limb movements of sleep;

  • 5. Other respiratory disorders, impotence, restless legs syndrome;
  • 6. History of stroke; or
  • 7. Chronic opioid medication use.

Place of Service

Inpatient hospital, Outpatient hospital, Physician’s office, Independent Diagnostic Treatment Facility (IDTF), home.

Additional Service Specifics

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

  • 1. Polysomnography and sleep studies may be billed as a complete procedure or as professional

and technical components.

  • a. Polysomnography and sleep studies are limited to one procedure per date of service by the

same or different provider.

  • b. The technical or the professional component cannot be billed by the same or different

provider on the same date of service as the complete procedure is billed.

  • c. The complete procedure is viewed as an episode of care that may start on one day and

conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that must be billed. The complete procedure must not be billed with two dates of service.

  • d. If components are billed, the technical and the professional components must be billed

with the date the service was rendered as the date of service.

  • 2. Separate reimbursement is not allowed for the following procedures on the same date of

service by the same or different provider:

  • a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with

sleep studies and polysomnography (CPT codes 95800 through 95811).

  • b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760

and 94761) with sleep studies and polysomnography (CPT codes 95800 through 95811).

  • c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour,

continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95800 through 95806) (age six and under).

  • d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT

code 94660) with polysomnography (CPT code 95800 through 95811).

  • e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT

codes 95800 through 95811).

  • f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes

95800 through 95811).

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)

Service Code
95851 (CPT) Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent