Does 95807 require prior authorization?

Yes, 95807 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 95807?

Medicare facility rate: $443.56. Non-facility rate: $443.56. Work RVU: 1.25.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

1.25

Facility

$443.56

Non-Facility

$443.56

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

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L36839 — Polysomnography and Other Sleep Studies

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A56903 — Billing and Coding: Polysomnography and Other Sleep Studies

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A53019 — Polysomnography and Sleep Studies Medical Policy Article

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