Sleep Studies – Commercial and Individual Exchange Medical Policyopen_in_new

HSAT is covered for adults with suspected OSA and attended full‑channel PSG (including split‑night or titration studies) is covered for children and for adults when HSAT is negative/indeterminate/technically inadequate or when specified conditions exist (e.g., obesity hypoventilation syndrome, central sleep apnea, narcolepsy evaluation after other causes excluded, chronic opioid use >3 months, ongoing seizures, refractory RLS/PLMD, parasomnia with injurious behavior, pre‑implant hypoglossal stimulator); actigraphy as a standalone test, abbreviated daytime PAP‑Nap studies, and PSG for circadian rhythm disorders, depression, or insomnia are not medically necessary, and HSAT is intended only for adults. Coverage requires documented HSAT results (to justify PSG when done), adequate HSAT performance (minimum 4 hours with nasal pressure, chest/abdominal RIP and oximetry), objective evidence for comorbid conditions (e.g., PFTs, ABG, BMI, cardiac data), documentation of prior treatments/responses (including chronic opioid use >3 months when claimed), and resolution/addressing of issues before repeat PSG/titration.