Does 95800 require prior authorization?

No, 95800 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 95800?

Medicare facility rate: $141.29. Non-facility rate: $141.29. Work RVU: 0.83.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.83

Facility

$141.29

Non-Facility

$141.29

Sleep study reports must document parameters monitored and the study start time and duration (day/night).
Reports must include total sleep time, sleep efficiency, and number and duration of awakenings.
For tests with sleep staging, the report must state the time and percent time spent in each sleep stage.
For tests monitoring sleep latency or maintenance of wakefulness (MSLT/MWT), reports must include latency to NREM and REM, individual sub-test latencies, mean sleep latency, and number of REM occurrences on MSLT.

Polysomnography and sleep studies are covered for the diagnostic evaluation of suspected sleep disorders (including obstructive sleep apnea) and for assessment of response to therapies (e.g., CPAP) when performed with physician review, interpretation, and report.
Studies that include sleep staging (polysomnography) are covered when they meet the policy's recording and documentation requirements.
Diagnostic polysomnography or other sleep testing is covered when the patient has symptoms or complaints of one of the conditions listed in LCD L36839.
A single polysomnogram (PSG) with EEG is ordinarily sufficient and covered to evaluate and diagnose suspected obstructive sleep apnea (OSA).
Diagnosis of narcolepsy is ordinarily confirmed by up to three Multiple Sleep Latency Test (MSLT) naps; MSLT (CPT 95805) performed appropriately is covered for this indication.
Outpatient sleep studies that meet the reasonable and necessary clinical criteria in Novitas LCD L35050 are covered.

L38528 — Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea

J05

A56903 — Billing and Coding: Polysomnography and Other Sleep Studies

J05

L36839 — Polysomnography and Other Sleep Studies

J05

A53019 — Polysomnography and Sleep Studies Medical Policy Article

J06

Ask Verity about documentation requirements, denial risks, or coverage in your state.