G0400, Home sleep test (hst) with type iv portable monitor, unattended; minimum of 3
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- 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.
- Reports must describe respiratory patterns including type (central/obstructive/periodic), number and duration of events, effect on oxygenation, sleep-stage and body-position relationships, and responses to diagnostic/therapeutic maneuvers.
- Reports must document cardiac rate/rhythm and any effects of sleep-disordered breathing on the ECG.
Key Coverage Criteria
- 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.
20 Active Policies
CGS-L36902, Polysomnography and Other Sleep Studies
J15
A56903, Billing and Coding: Polysomnography and Other Sleep Studies
J5
A53019, Polysomnography and Sleep Studies Medical Policy Article
J6
WPS-L38528, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
J8
WPS-L36839, Polysomnography and Other Sleep Studies
J8
A57496, Billing and Coding: Polysomnography and Sleep Testing
J9
FIRST_COAST-L33405, Polysomnography and Sleep Testing
J9
NORIDIAN-L36861, Polysomnography and Other Sleep Studies
JF
NOVITAS-L35050, Outpatient Sleep Studies
JH
PALMETTO-JJ-L36593, Polysomnography
JJ
A56923, Billing and Coding: Outpatient Sleep Studies
JL
PALMETTO-JM-L36593, Polysomnography
JM
CARELON-sleep-disorder-management-2024-10-20-updated-2025-07-01-for-anthem-bcbs-ohio-medicaid-and-regence-only-deferred-to-2025-12-01, Sleep Disorder Management
UMR-POL-UMR-sleep-studies, Sleep Studies
SUREST-POL-SUREST-sleep-studies, Sleep Studies
CARELON-sleep-disorder-management-2025-11-15-uc, Sleep Disorder Management
AETNA-CPB-0336, Acoustic Pharyngometers and SNAP Testing System
AETNA-CPB-0752, Obstructive Sleep Apnea in Children
A56995, Billing and Coding: Polysomnography
A57049, Billing and Coding: Polysomnography and Other Sleep Studies
Related Codes
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