Sleep Management Guidelines

EviCore covers medically necessary HSAT, in‑lab PSG (diagnostic, split‑night, titration), MSLT/MWT, PAP device initiation/continuation (CPAP/APAP/bilevel/ASV) and implantable device testing (HGNS, TPNS) when specific criteria are met, and excludes routine asymptomatic pre‑op testing (e.g., bariatric), PSG for typical arousal disorders or insomnia without SDB concern, opioid‑attributed CSA for TPNS, and listed investigational devices/procedures (e.g., iNAP, eXciteOSA, standalone actigraphy). Coverage requires documented symptoms or validated questionnaire results, specified physiologic thresholds (AHI/REI, central AHI, BMI, PaCO2/ABG/bicarbonate, etc.), ability to safely perform HSAT when used, comprehensive clinical documentation and prior test reports as applicable, and objective PAP adherence (≥4 hours/night on ≥70% of nights over a consecutive 30‑day period) plus other indication‑specific criteria (MSLT sequencing, split‑night AHI/time rules, bilevel/ASV/TPNS criteria, supply frequency limits).