Polysomnography for Non-Respiratory Sleep Disorders

This policy covers diagnostic nocturnal polysomnography (PSG), with next‑day multiple sleep latency testing (MSLT) when indicated, for evaluation of non‑respiratory sleep disorders including suspected narcolepsy (types 1 and 2) and idiopathic hypersomnia, parasomnias such as REM sleep behavior disorder, periodic limb movement disorder (when OSA is excluded/adequately treated and specific symptoms are present), and major NREM parasomnias (sleepwalking, confusional arousals, night terrors). PSG/MSLT must follow standard MSLT protocols and be used to exclude other sleep disorders before MSLT; it is not medically necessary in typical benign cases or for PLMD with concurrent untreated OSA/RLS/narcolepsy/RBD and is considered experimental/investigational for non‑respiratory disorders that do not meet the stated criteria (eg, nightmare disorder, bruxism).

"Multiple sleep latency test (MSLT) performed the day after polysomnography (PSG) is medically necessary for evaluation of suspected narcolepsy or idiopathic hypersomnia."