G47.419 — Narcolepsy without cataplexy
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- If a sleep study is performed for less than six hours, bill with modifier 52 and report the appropriately reduced original charge.
- Medical records must document the signs, symptoms, or complaints demonstrating the indication for sleep testing; if the patient is admitted, documentation must explicitly support inpatient admission and indications.
- Persuasive medical evidence of medical necessity must be provided when additional tests beyond usual limits (e.g., >1 HST/year, >2 PSG/year, >3 MSLT naps) are claimed.
- MSLT (CPT 95805) includes all naps done in a single day; only one unit of CPT 95805 should be submitted for that day's MSLT.
Key Coverage Criteria
- 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.
- Psychiatric/psychological services are covered when there is a reasonable expectation that withdrawing treatment would cause the patient's condition to deteriorate, relapse, or require hospitalization.
- CORF social and psychological services are covered when indicated and may be provided by qualified social workers (minimum BS) or psychologists (minimum Master’s level).
- Psychiatric diagnostic procedures may be billed once per day and are covered at the outset of an illness or suspected illness, or again for a new episode after a hiatus or on (re)admission for complications of the underlying condition.
20 Active Policies
L34616 — Psychiatry and Psychology Services
J05
L37003 — MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
J05
L38528 — Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
J05
A57575 — Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
J05
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