Polysomnography

This LCD covers polysomnography (PSG) and certain home sleep tests (HST Type II–IV) primarily for diagnosing narcolepsy, obstructive sleep apnea, selected parasomnias, neuromuscular-related sleep disorders, and PLMD/RLS when clinical criteria are met. Coverage requires accredited facilities, appropriately credentialed physicians and technologists, retention of supporting documentation, and specific procedural thresholds (e.g., PSG ≥6 hours, split-night CPAP titration >3 hours); HST is limited to OSA diagnosis and is excluded for multiple comorbid conditions and non-covered indications.

"Polysomnography (PSG) is covered when it records sleep staging with continuous monitoring for 6 or more hours and includes physician review, interpretation, and report."

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