Download 2.01.99 - Premera Blue Cross

MEDICAL POLICY – 2.01.99
Polysomnography for Non‒Respiratory Sleep Disorders
Effective Date: Mar. 1, 2017
RELATED MEDICAL POLICIES:
Last Revised:
Feb. 14, 2017
2.01.503
Replaces:
N/A
Polysomnography and Home Sleep Study for Diagnosis of
Obstructive Sleep Apnea
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | CODING | RELATED INFORMATION | EVIDENCE REVIEW |
REFERENCES | HISTORY
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Introduction
A sleep study records several different bodily processes as you sleep. A full sleep study looks at
the stages of waking and sleeping, rapid eye movement, the effort it takes to breathe, airflow,
oxygen in the blood, whether breathing stops for short periods, or unusual movement or
behavior. Most sleep studies look at whether a person stops breathing for short periods of time
during sleep. There are other sleep problems, though, related to unusual movement or
behaviors. These are generally called sleep-related movement disorders. This policy discusses
when a sleep study may be covered for a suspected sleep-related movement disorder.
Note:
The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
Policy Coverage Criteria
Procedure
Investigational Indications
Polysomnography (PSG)
Polysomnography (PSG) is considered investigational for the
diagnosis of non‒respiratory sleep disorders not meeting the
criteria in this policy, including but not limited to nightmare
disorder, depression, sleep-related bruxism, or noninjurious
disorders of arousal.
Purpose / Condition
Medically Necessary Coverage Criteria
Suspected narcolepsy
Multiple sleep latency test performed on the day after the PSG
idiopathic hypersomnia
may be considered medically necessary in the evaluation of
suspected narcolepsy or idiopathic hypersomnia.
Parasomnias
PSG may be considered medically necessary when evaluating
patients with parasomnias when there is a history of sleep
related injurious or potentially injurious disruptive behaviors.
Periodic limb movement
PSG may be medically necessary when a diagnosis of periodic
disorder (PLMD)
limb movement disorder (PLMD) is considered when there is:

A complaint of repetitive limb movement during sleep by the
patient or an observer
AND

There is no other concurrent sleep disorder
AND

At least one of the following is present:
o
Frequent awakenings
o
Fragmented sleep
o
Difficulty maintaining sleep
o
Excessive daytime sleepiness
PSG for the diagnosis of PLMD is considered not medically
necessary when there is concurrent untreated obstructive sleep
apnea, restless legs syndrome, narcolepsy, or rapid eye
movement sleep behavior disorder.
∞
Coding
CPT
95805
Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and
interpretation of physiological measurements of sleep during multiple trials to assess
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CPT
sleepiness
95808
Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep,
attended by a technologist
95810
Polysomnography; age 6 years or older, sleep staging with 4 or more additional
parameters of sleep, attended by a technologist.
95811
Polysomnography; age 6 years or older, sleep staging with 4 or more additional
parameters of sleep, with initiation of continuous positive airway pressure therapy or
bilevel ventilation, attended by a technologist.
95782
Polysomnography; younger than 6 years, sleep staging with 4 or more additional
parameters of sleep, attended by a technologist
95783
Polysomnography; younger than 6 years, sleep staging with 4 or more additional
parameters of sleep, with initiation of continuous positive airway pressure therapy or
bilevel ventilation, attended by a technologist.
Note:
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
∞
Related Information
Polysomnography (PSG) is a recording of multiple physiologic parameters relevant to sleep. The
standard full polysomnogram includes:

Electroencephalography to differentiate the various stages of sleep and wake

Chin electromyography (EMG) and electrooculography to assess muscle tone and detect
rapid eye movement (REM) sleep

Respiratory effort, airflow, blood oxygen saturation (oximetry), and electrocardiography to
assess apneic events

Anterior tibialis EMG to assess periodic limb movements during sleep

Video recording to detect any unusual behavior
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Hypersomnias
The hypersomnias include such disorders as narcolepsy, Klein-Levine syndrome, and idiopathic
hypersomnolence. Narcolepsy is a neurologic disorder characterized predominantly by
abnormalities of REM sleep, some abnormalities of non-REM (NREM) sleep, and the presence of
excessive daytime sleepiness that cannot be fully relieved by any amount of sleep. The classic
symptoms include hypersomnolence, cataplexy, sleep paralysis, and hypnagogic (onset of sleep)
hallucinations. Cataplexy refers to the total or partial loss of muscle tone in response to sudden
emotion. Most patients with cataplexy have abnormally low levels of hypocretin-1 (orexin A) in
the cerebrospinal fluid.1 Narcolepsy type 1 (narcolepsy with cataplexy) is defined as excessive
daytime sleepiness and at least 1 of the following criteria: (a) hypocretin deficiency or (b)
cataplexy and a positive multiple sleep latency test (MSLT). In the MSLT, the patient lies down in
a dark quiet room to assess the time to enter the different stages of sleep. The test is repeated
every 2 hours throughout the day, and the maximum time allowed to fall sleep is typically set at
20 minutes. Patients with narcolepsy often have a mean sleep latency of less than 5 minutes and
2 or more early-onset REM periods during the MSLT naps. People with idiopathic hypersomnia
fall asleep easily but typically do not reach REM sleep during the MSLT. Narcolepsy type 2
(narcolepsy without cataplexy) is defined by chronic sleepiness plus a positive MSLT; hypocretin1 levels are in the normal range in most patients.
Parasomnias
Parasomnias are abnormal behavioral, experiential, or physiologic events that occur during entry
into sleep, within sleep, or during arousals from sleep. Parasomnias can result in a serious
disruption of sleep-wake schedules and family functioning. Some, particularly sleepwalking,
sleep terrors, and REM sleep behavior disorder (RBD), can cause injury to the patient and others.
Parasomnias are classified into parasomnias associated with REM sleep, parasomnias associated
with non-REM (NREM) sleep, and other parasomnias.
Parasomnias Associated with REM Sleep
REM sleep is normally accompanied by muscle atonia, in which there is an almost complete
paralysis of the body through inhibition of motor neurons. In patients with RBD, muscle tone is
maintained during REM sleep. This can lead to abnormal or disruptive behaviors associated with
vivid dreams such as talking, laughing, shouting, gesturing, grabbing, flailing arms, punching,
kicking, sitting up or leaping from bed, and running.2 Violent episodes that carry a risk of harm
to the patient or bed partner may occur up to several times nightly. Idiopathic RBD is associated
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with the development of degenerative synucleinopathies (Parkinson disease, dementia with
Lewy bodies, multiple systems atrophy) in about half of patients. Guidelines recommend
maintaining a safe sleeping environment for both the patient and bed partner along with
medical therapy. Other parasomnias associated with REM sleep are recurrent isolated sleep
paralysis and nightmare disorder.
Parasomnias Associated with NREM Sleep
Disorders of arousal from NREM sleep result from the intrusion of wake into NREM sleep. These
include confusional arousals, sleepwalking, and sleep terrors. In these parasomnias, the patient
has incomplete awakening from NREM sleep, usually appears awake with eyes open, is
unresponsive to external stimuli, and is amnestic to the event. Sleepwalking can range from calm
behaviors such as walking through a house to violent and/or injurious behaviors such as
jumping out of a second story window. Patients with sleep terrors (also called night terrors)
typically awaken with a loud scream and feeling of intense fear, jump out of bed, and
occasionally may commit a violent act.
Other Parasomnias
The category of “other parasomnias” has no specific relation to sleep stage and includes sleeprelated dissociative disorders, sleep-related enuresis, sleep-related groaning, exploding head
syndrome, sleep-related hallucinations, and sleep-related eating disorder. Diagnosis of these
disorders is primarily clinical, although PSG may be used for differential diagnosis.

In sleep-related dissociative disorders, behaviors occur during an awakening but the patient
is amnestic to them.

Sleep-related enuresis (bedwetting) is characterized by recurrent involuntary voiding in
patients greater than 5 years of age.

Sleep-related groaning is a prolonged vocalization that can occur during either NREM or
REM sleep.

Exploding head syndrome is a sensation of a sudden loud noise or explosive feeling within
the head upon falling asleep or during an awakening from sleep.

Sleep-related hallucinations are hallucinations that occur on falling asleep or on awakening.
Page | 5 of 15

Sleep-related eating disorder is characterized by recurrent episodes of arousals from sleep
with involuntary eating or drinking. Patients may have several episodes during the night,
typically eat foods that they would not eat during the day, and may injure themselves by
cooking during sleep.
Sleep-Related Movement Disorders
Sleep-related movement disorders include restless legs syndrome (RLS) and periodic limb
movement disorder (PLMD).
Restless Legs Syndrome
RLS is a neurologic disorder characterized by uncomfortable or odd sensations in the leg that
usually occur during periods of relaxation, such as while watching television, reading, or
attempting to fall asleep. Symptoms occur primarily in the evening. The sensations are typically
described as creeping, crawling, itchy, burning, or tingling. There is an urge to move in an effort
to relieve these feelings, which may be partially relieved by activities such as rubbing or slapping
the leg, bouncing the feet, or walking around the room.
Periodic Limb Movement Disorder
Periodic limb movements are involuntary, stereotypic, repetitive limb movements during sleep,
which most often occur in the lower extremities, including the toes, ankles, knees, and hips, and
occasionally in the upper extremities. The repetitive movements can cause fragmented sleep
architecture, with frequent awakenings, a reduction in slow wave sleep and decreased sleep
efficiency, leading to excessive daytime sleepiness. PLMD alone is thought to be rare because
periodic limb movements are typically associated with RLS, RBD, or narcolepsy and represent a
distinct diagnosis from PLMD.3
∞
Evidence Review
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Description
Polysomnography (PSG) recordings multiple physiologic parameters relevant to sleep. Video
recording may also be performed during PSG to assess parasomnias such as rapid eye
movement (REM) sleep behavior disorder (RBD).
Evidence Review
The objective of this evidence review is to address polysomnography for non‒respiratory sleep
disorders, which include the hypersomnias (e.g., narcolepsy), parasomnias (e.g., sleep terrors,
sleepwalking, rapid eye movement sleep behavior disorder) and movement disorders (e.g.,
restless legs syndrome, periodic limb movement disorder).
Hypersomnia
Evidence reviewed by AASM included a data review of 1602 patients, of whom 176 patients had
narcolepsy and 1426 had other sleep disorders.5 However, 7% of obstructive sleep apnea
patients and 5% of other sleep disorders patients had 2 sleep onset REMs (SOREMs) on multiple
sleep latency test (MSLT), leading to a low predictive value for narcolepsy. No data were found
that validated the maintenance of wakefulness test (which measures a patient’s ability to stay
awake in a quiet sleep-inducing environment), limited or partial polysomnography (PSG),
portable recording, isolated MSLT, or separately performed PSG and MSLT as an alternative to
the criterion standard of nocturnal PSG with an MSLT on the following day for the diagnosis of
narcolepsy. The 2005 evidence review found that the presence of 2 or more early sleep-onset
latency episodes was associated with a sensitivity of 0.78 and specificity of 0.93 for the diagnosis
of narcolepsy.1 Based on the evidence reviewed, the updated 2005 AASM guidelines indicated
that PSG should be used to rule out other potential causes of sleepiness followed by an MSLT to
confirm the clinical impression of narcolepsy. These tests assume greater significance if
cataplexy is lacking. In the absence of cataplexy and when there is one or more of the other
symptoms, the laboratory criteria are required to establish the diagnosis of narcolepsy.
For individuals who have suspected hypersomnia who receive polysomnography (PSG), the
evidence includes a systematic review on diagnostic accuracy. Relevant outcomes are test
accuracy, symptoms, functional outcomes, and quality of life. Evidence indicates that PSG
followed by the multiple sleep latency test is associated with moderate sensitivity and high
specificity in support of the diagnosis of narcolepsy. The evidence is sufficient to determine that
the technology results in a meaningful improvement in the net health outcome.
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Parasomnia
Typical or Benign Parasomnia
Evidence reviewed by AASM in 1997 indicated that typical sleepwalking or sleep terrors, with
onset in childhood, a positive family history, occurrence during the first third of the night,
amnesia for the events, prompt return to sleep following the events, and relatively benign
automatistic behaviors, may be diagnosed on the basis of their historical clinical features.5 This
conclusion was based on very consistent descriptive literature (case series and cohort studies).
For individuals who have typical or benign parasomnia who receive PSG, the evidence includes
systematic reviews of studies on diagnostic accuracy and controlled cohort studies. Relevant
outcomes are test accuracy, symptoms, functional outcomes, and quality of life. The evidence
indicates that typical and benign parasomnias (e.g., sleepwalking, sleep terrors) may be
diagnosed on the basis of their clinical features and do not require PSG. The evidence is
sufficient to determine that the technology is unlikely to improve the net health outcome.
Violent or Potentially Injurious Parasomnia
When events are not typical of benign partial arousals and where other diagnoses, prognoses,
and interventions should be considered, PSG was recommended by AASM. The evidence
reviewed in 1997 included only 3 articles on disorders of arousal and 2 for REM sleep behavior
disorder (RBD) that included comparison data for normal controls. Most articles supporting the
utility of PSG were limited by biases inherent in uncontrolled clinical reports. The need for PSG
was also indicated in a 2011 review of parasomnias that concluded, although RBD is the only
parasomnia that requires PSG for diagnosis, PSG may be needed to rule out another sleep
pathology, such as sleep-disordered breathing or periodic limb movements (PLMs) of sleep, that
might cause a parasomnia.6 Evidence reviewed in a 2010 AASM best practice guide indicated
that sleep-related injuries are a significant portion of the morbidity in RBD, with a prevalence in
diagnosed RBD patients ranging from 30% to 81%.2 Types of injuries ranged from ecchymoses
and lacerations to fractures and subdural hematomas, with ecchymoses and lacerations being
significantly more common than fractures. In a series of 92 patients, 64% of the bed partners
sustained punches, kicks, attempted strangulation, and assault with objects. Minimal diagnostic
criteria for RBD requires the presence of REM sleep without atonia, defined as sustained or
intermittent elevation of submental electromyogram (EMG) tone or excessive phasic muscle
activity in the limb EMG.2 Two clinical series with over 100 cases each of patients with various
parasomnias found that PSG had an overall yield of clinical utility in 65% and 91% of cases. A
Page | 8 of 15
systematic review on the diagnosis of RBD found that diagnostic accuracy is increased with
combined use of clinical history and video PSG to document the intermittent or sustained loss of
muscle atonia or actual observation of RBD occurrences.7
For individuals who have violent or potentially injurious parasomnia who receive PSG, the
evidence includes systematic reviews of studies on diagnostic accuracy and controlled cohort
studies. Relevant outcomes are test accuracy, symptoms, functional outcomes, and quality of
life. For the diagnosis of rapid eye movement (REM) sleep behavior disorder (RBD), combined
use of clinical history and PSG to document loss of muscle atonia during REM sleep increases
diagnostic accuracy and is considered the criterion standard for diagnosis. Diagnostic accuracy is
increased with video recording during PSG to assess parasomnias such as RBD. The evidence is
sufficient to determine that the technology results in a meaningful improvement in the net
health outcome.
Sleep-Related Movement Disorder
Restless Legs Syndrome
The 4 cardinal diagnostic features of restless legs syndrome (RLS) include (1) an urge to move
the limbs that is usually associated with paresthesias or dysesthesias, (2) symptoms that start or
worsen with rest, (3) at least partial relief of symptoms with physical activity, and (4) worsening
of symptoms in the evening or at night.3 Evidence reviewed by AASM included a case-control
study that found, compared with controls, RLS patients had reduced total sleep time, reduced
sleep efficiency, prolonged sleep latencies, decreased slow-wave sleep, and increased nocturnal
awakening. However, because the principal symptoms of RLS occur during wake, RLS does not
require PSG for diagnosis, except where uncertainty exists in the diagnosis.1,5 RLS frequently also
has a primary motor symptom that is characterized by the occurrence of periodic limb
movements (PLMs) in sleep. PLMs occur in 80% to 90% of patients who have RLS and support
the diagnosis of RLS. In cases of frequent PLMs during PSG and a subjective perception of poor
sleep in the absence of RLS or sleep-related breathing disorder, periodic limb movement
disorder (PLMD) can be diagnosed (see next).3
For individuals who have restless legs syndrome (RLS) who receive PSG, the evidence includes
systematic reviews of studies on diagnostic accuracy and controlled cohort studies. Relevant
outcomes are test accuracy, symptoms, functional outcomes, and quality of life. RLS does not
require PSG because RLS is a sensorimotor disorder, the symptoms of which occur
predominantly when awake. Therefore, PSG results are generally not useful. The evidence is
sufficient to determine that the technology is unlikely to improve the net health outcome.
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Periodic Limb Movement Disorder
Evidence reviewed by AASM showed difficulty in diagnosing PLMD without PSG.5 In a series of
123 patients evaluated for chronic insomnia, a PLMD diagnosis was confirmed in 5 patients and
discovered with PSG in another 10 patients. The PLMD scale from a sleep questionnaire had low
sensitivity and specificity. Actigraphy, evoked potentials, and blink reflexes have been found to
have little diagnostic specificity or utility. PSG-based diagnosis of PLMD correlated best with
frequent awakening at night. In a series of 1171 patients who had PSG at 1 sleep disorders
center, 67 (6%) patients had PLMD as the primary and sole sleep diagnosis. The mean sleep
efficiency was 53% and daytime sleepiness was reported by 60% of the cohort. The PLMD
patients reported disturbed sleep during a mean of 4 nights per week for a mean of 7 years.
For individuals who have periodic limb movement disorder (PLMD) who receive PSG, the
evidence includes a systematic review. Relevant outcomes are test accuracy, symptoms,
functional outcomes, and quality of life. PSG with electromyography of the anterior tibialis is the
only method available to diagnose PLMD, but this sleep-related movement disorder is rare and
should only be evaluated using PSG in the absence of symptoms of other disorders. The
evidence is sufficient to determine that the technology results in a meaningful improvement in
the net health outcome.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in October 2016 did not identify any ongoing or unpublished
trials that would likely influence this review.
Practice Guidelines and Position Statements
American Academy of Sleep Medicine
In 2005, the American Academy of Sleep Medicine (AASM) published practice parameters for
polysomnography (PSG) and related procedures.1 AASM made the following recommendations
on the use of PSG for nonrespiratory indications (see Table 1).
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Table 1: AASM Practice Parameters on PSG for Nonrespiratory Indications
Recommendation
Grade
Polysomnography and a multiple sleep latency test performed on the day after the
Standard
polysomnographic evaluation are routinely indicated in the evaluation of suspected narcolepsy
Common, uncomplicated, noninjurious parasomnias, such as typical disorders of arousal,
Standard
nightmares, enuresis, sleeptalking, and bruxism, can usually be diagnosed by clinical evaluation
alone
Polysomnography is not routinely indicated in cases of typical, uncomplicated, and noninjurious
Option
parasomnias when the diagnosis is clearly delineated
A clinical history, neurologic examination, and a routine EEG obtained while the patients is
Option
awake and asleep are often sufficient to establish the diagnosis and permit the appropriate
treatment of a sleep related seizure disorder. The need for a routine EEG should be based on
clinical judgment and the likelihood that the patient has a sleep relate seizure disorder
Polysomnography is not routinely indicated for patients with a seizure disorder who have no
Option
specific complaints consistent with a sleep disorder
Polysomnography is indicated when evaluating patients with sleep behaviors suggestive of
Guideline
parasomnias that are unusual or atypical because of the patient’s age at onset; the time,
duration or frequency of occurrence of the behavior; or the specifics of the particular motor
patterns in question
Polysomnography is indicated in evaluating sleep related behaviors that are violent or
Option
otherwise potentially injurious to the patient or others
Polysomnography may be indicated in situations with forensic considerations (e.g., if onset
Option
follows trauma or if the events themselves have been associated with personal injury)
Polysomnography may be indicated when the presumed parasomnia or sleep related seizure
Option
disorder does not respond to conventional therapy
Polysomnography is indicated when a diagnosis of periodic limb movement disorder is
Standard
considered because of complaints by the patient or an observer of repetitive limb movement
during sleep and frequent awakenings, fragmented sleep, difficulty maintaining sleep, or
excessive daytime sleepiness
Intra-individual night-to-night variability exists in patients with periodic limb movement sleep
Option
disorder, and a single study might not be adequate to establish this diagnosis
Polysomnography is not routinely indicated to diagnose or treat restless legs syndrome, except
Standard
where uncertainty exists in the diagnosis
Polysomnography is not routinely indicated for the diagnosis of circadian rhythm sleep
disorders
AASM: American Academy of Sleep Medicine; EEG: electroencephalography
Page | 11 of 15
Standard
In 2012, AASM published practice parameters for the nonrespiratory indications for PSG and
multiple sleep latency testing in children.4 The following recommendations for PSG and MSLT
were made (see Table 2).
Table 2: AASM Practice Parameters on PSG for Nonrespiratory Indications
in Children
Recommendation
Grade
PSG is indicated for children suspected of having periodic limb movement disorder (PLMD) for
Standard
diagnosing PLMD
The MSLT, preceded by nocturnal PSG, is indicated in children as part of the evaluation for
Standard
suspected narcolepsy
Children with frequent NREM parasomnias, epilepsy, or nocturnal enuresis should be clinically
Guideline
screened for the presence of comorbid sleep disorders and polysomnography should be
performed if there is a suspicion for sleep-disordered breathing or periodic limb movement
disorder
The MSLT, preceded by nocturnal PSG, is indicated in children suspected of having hypersomnia
Option
from causes other than narcolepsy to assess excessive sleepiness and to aid in differentiation
from narcolepsy
The polysomnogram using an expanded EEG montage is indicated in children to confirm the
Option
diagnosis of an atypical or potentially injurious parasomnia or differentiate a parasomnia from
sleep-related epilepsy when the initial clinical evaluation and standard EEG are inconclusive
Polysomnography is indicated in children suspected of having RLS who require supportive data
Option
for diagnosing RLS
Polysomnography is not routinely indicated for evaluation of children with sleep-related
Standard
bruxism
AASM: American Academy of Sleep Medicine; EEG: electroencephalography; MSLT: multiple sleep latency test; NREM:
non‒rapid eye movement; PSG: polysomnography; RLS: restless legs syndrome.
AASM issued a 2012 practice parameter on the treatment of restless legs syndrome (RLS) and
periodic limb movement disorder in adults.3 The practice parameter noted many different
treatment efficacy measures are used to assess RLS due to its multifaceted nature. Measures
included a number of various subjective scales; the only objective measurements are sleeprelated parameters by PSG or actigraphy.
AASM issued a 2010 Best Practice Guide on the treatment of nightmare disorders in adults
(classified as a parasomnia).8 AASM states the overnight PSG is not routinely used to assess
nightmare disorder but may be used to exclude other parasomnias or sleep-disordered
Page | 12 of 15
breathing. PSG may underestimate the incidence and frequency of posttraumatic stress
disorder‒associated nightmares.
AASM issued a 2010 best practice guide on the treatment of rapid eye movement sleep
behavior disorder (RBD).2 Minimal diagnostic criteria for RBD included:

Presence of R[EM] sleep without atonia, defined as sustained or intermittent elevation of
submental EMG [electromyographic] tone or excessive phasic muscle activity in the limb
EMG;


At least 1 of the following:
o
Sleep related injurious or potentially injurious disruptive behaviors by history;
o
Abnormal R[EM] behaviors documented on polysomnogram (PSG);
Absence of epileptiform activity during R[EM] sleep unless RBD can be clearly distinguished
from any concurrent R[EM] sleep-related seizure disorder;

Sleep disturbance not better explained by another sleep disorder, medical or neurological
disorder, mental disorder, medication use, or substance use disorder.
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage
decisions are left to the discretion of local Medicare carriers.
Regulatory Status
A large number of polysomnography devices have been approved since 1986. U.S. Food and
Drug Administration product code: OLV.
∞
References
Page | 13 of 15
1.
Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related
procedures: an update for 2005. Sleep. Apr 2005;28(4):499-521. PMID 16171294
2.
Aurora RN, Zak RS, Maganti RK, et al. Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep
Med. Feb 15 2010;6(1):85-95. PMID 20191945
3.
Aurora RN, Kristo DA, Bista SR, et al. The treatment of restless legs syndrome and periodic limb movement disorder in adults-an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy
of Sleep Medicine Clinical Practice Guideline. Sleep. Aug 01 2012;35(8):1039-1062. PMID 22851801
4.
Aurora RN, Lamm CI, Zak RS, et al. Practice parameters for the non-respiratory indications for polysomnography and multiple
sleep latency testing for children. Sleep. Nov 01 2012;35(11):1467-1473. PMID 23115395
5.
Chesson AL, Jr., Ferber RA, Fry JM, et al. The indications for polysomnography and related procedures. Sleep. Jun
1997;20(6):423-487. PMID 9302726
6.
Goldstein CA. Parasomnias. Dis Mon. Jul 2011;57(7):364-388. PMID 21807161
7.
Neikrug AB, Ancoli-Israel S. Diagnostic tools for REM sleep behavior disorder. Sleep Med Rev. Oct 2012;16(5):415-429. PMID
22169258
8.
Aurora RN, Zak RS, Auerbach SH, et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med.
Aug 15 2010;6(4):389-401. PMID 20726290
∞
History
Date
Comments
02/14/17
New policy. Created separate policy for non-respiratory sleep disorders. Policy
statements previously included in 2.01.503 Polysomnography and Home Sleep Study
for Diagnosis of Obstructive Sleep Apnea. Added to the Medicine section.
∞
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
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CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2017 Premera
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Page | 14 of 15
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
∞
Page | 15 of 15
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Cross. There may be key dates in this notice. You may need to take action
by certain deadlines to keep your health coverage or help with costs. You
have the right to get this information and help in your language at no cost.
Call 800-722-1471 (TTY: 800-842-5357).
አማሪኛ (Amharic):
ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue
Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ።
የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ
ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት
አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ።
‫( العربية‬Arabic):
‫ قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو‬.‫يحوي ھذا اإلشعار معلومات ھامة‬
‫ قد تكون ھناك تواريخ مھمة‬.Premera Blue Cross ‫التغطية التي تريد الحصول عليھا من خالل‬
‫ وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة‬.‫في ھذا اإلشعار‬
‫ اتصل‬.‫ يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة‬.‫في دفع التكاليف‬
800-722-1471 (TTY: 800-842-5357)‫بـ‬
中文 (Chinese):
本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的
申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期
之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母
語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。
037338 (07-2016)
Oromoo (Cushite):
Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa
yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee
odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa
ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf
yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan
jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.
Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.
Français (French):
Cet avis a d'importantes informations. Cet avis peut avoir d'importantes
informations sur votre demande ou la couverture par l'intermédiaire de
Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous
devrez peut-être prendre des mesures par certains délais pour maintenir
votre couverture de santé ou d'aide avec les coûts. Vous avez le droit
d'obtenir cette information et de l’aide dans votre langue à aucun coût.
Appelez le 800-722-1471 (TTY: 800-842-5357).
Kreyòl ayisyen (Creole):
Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen
enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti
asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan
avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka
kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo.
Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,
san ou pa gen pou peye pou sa. Rele nan 800-722-1471
(TTY: 800-842-5357).
Deutsche (German):
Diese Benachrichtigung enthält wichtige Informationen. Diese
Benachrichtigung enthält unter Umständen wichtige Informationen
bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera
Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser
Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln
müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten
zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in
Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471
(TTY: 800-842-5357).
Hmoob (Hmong):
Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum
tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv
thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue
Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv
no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub
dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj
yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob
ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau
ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471
(TTY: 800-842-5357).
Iloko (Ilocano):
Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a
pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion
maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue
Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar.
Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti
partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti
salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti
daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti
bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).
Italiano (Italian):
Questo avviso contiene informazioni importanti. Questo avviso può contenere
informazioni importanti sulla tua domanda o copertura attraverso Premera
Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe
essere necessario un tuo intervento entro una scadenza determinata per
consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di
ottenere queste informazioni e assistenza nella tua lingua gratuitamente.
Chiama 800-722-1471 (TTY: 800-842-5357).
日本語 (Japanese):
この通知には重要な情報が含まれています。この通知には、Premera Blue
Cross の申請または補償範囲に関する重要な情報が含まれている場合があ
ります。この通知に記載されている可能性がある重要な日付をご確認くだ
さい。健康保険や有料サポートを維持するには、特定の期日までに行動を
取らなければならない場合があります。ご希望の言語による情報とサポー
トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話
ください。
Română (Romanian):
Prezenta notificare conține informații importante. Această notificare
poate conține informații importante privind cererea sau acoperirea asigurării
dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie
în această notificare. Este posibil să fie nevoie să acționați până la anumite
termene limită pentru a vă menține acoperirea asigurării de sănătate sau
asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste
informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471
(TTY: 800-842-5357).
한국어 (Korean):
본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에
관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를
포함하고 있을 수 있습니다. 본 통지서에는 핵심이 되는 날짜들이 있을 수
있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기
위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다.
귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는
권리가 있습니다. 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오.
Pусский (Russian):
Настоящее уведомление содержит важную информацию. Это
уведомление может содержать важную информацию о вашем
заявлении или страховом покрытии через Premera Blue Cross. В
настоящем уведомлении могут быть указаны ключевые даты. Вам,
возможно, потребуется принять меры к определенным предельным
срокам для сохранения страхового покрытия или помощи с расходами.
Вы имеете право на бесплатное получение этой информации и
помощь на вашем языке. Звоните по телефону 800-722-1471
(TTY: 800-842-5357).
ລາວ (Lao):
ແຈ້ ງການນ້ີ ມີຂ້ໍ ມູ ນສໍາຄັ ນ. ແຈ້ ງການນ້ີ ອາດຈະມີຂ້ໍ ມູ ນສໍາຄັ ນກ່ ຽວກັ ບຄໍາຮ້ ອງສະ
ໝັ ກ ຫື ຼ ຄວາມຄຸ້ ມຄອງປະກັ ນໄພຂອງທ່ ານຜ່ ານ Premera Blue Cross. ອາດຈະມີ
ວັ ນທີສໍາຄັ ນໃນແຈ້ ງການນີ້. ທ່ ານອາດຈະຈໍາເປັນຕ້ ອງດໍາເນີນການຕາມກໍານົ ດ
ເວລາສະເພາະເພື່ອຮັ ກສາຄວາມຄຸ້ ມຄອງປະກັ ນສຸ ຂະພາບ ຫື ຼ ຄວາມຊ່ ວຍເຫື ຼ ອເລື່ອງ
ຄ່ າໃຊ້ ຈ່ າຍຂອງທ່ ານໄວ້ . ທ່ ານມີສິດໄດ້ ຮັ ບຂ້ໍ ມູ ນນ້ີ ແລະ ຄວາມຊ່ ວຍເຫື ຼ ອເປັນພາສາ
ຂອງທ່ ານໂດຍບໍ່ເສຍຄ່ າ. ໃຫ້ ໂທຫາ 800-722-1471 (TTY: 800-842-5357).
ភាសាែខម រ (Khmer):
េសចកត ីជូនដំណឹងេនះមានព័ត៌មានយា៉ងសំខាន់។ េសចកត ីជូនដំណឹងេនះរបែហល
ជាមានព័ត៌មានយា៉ងសំខាន់អំពីទរមង់ែបបបទ ឬការរា៉ប់រងរបស់អនកតាមរយៈ
Premera Blue Cross ។ របែហលជាមាន កាលបរ ិេចឆ ទសំខាន់េនៅកនុងេសចកត ីជូន
ដំណឹងេនះ។ អន ករបែហលជារតូវការបេញច ញសមតថ ភាព ដល់កំណត់ៃថង ជាក់ចបាស់
នានា េដើមបីនឹងរកសាទុកការធានារា៉ប់រងសុខភាពរបស់អនក ឬរបាក់ជំនួយេចញៃថល ។
អន កមានសិទធិទទួ លព័ត៌មានេនះ និងជំនួយេនៅកនុងភាសារបស់អនកេដាយមិនអស
លុយេឡើយ។ សូ មទូ រស័ពទ 800-722-1471 (TTY: 800-842-5357)។
ਪੰ ਜਾਬੀ (Punjabi):
ਇਸ ਨੋਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ
ਕਵਰੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ
ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤੁਸੀ ਜਸਹਤ ਕਵਰੇਜ ਿਰੱ ਖਣੀ ਹੋਵੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ
ਇਛੁੱ ਕ ਹੋ ਤਾਂ ਤੁਹਾਨੂੰ ਅੰ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੁੱ ਕਣ ਦੀ ਲੋ ੜ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੂੰ
ਮੁਫ਼ਤ ਿਵੱ ਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ੍ਰਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ
800-722-1471 (TTY: 800-842-5357).
‫( فارسی‬Farsi):
‫اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم‬. ‫اين اعالميه حاوی اطالعات مھم ميباشد‬
‫ به تاريخ ھای مھم در‬.‫ باشد‬Premera Blue Cross ‫تقاضا و يا پوشش بيمه ای شما از طريق‬
‫شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه‬. ‫اين اعالميه توجه نماييد‬
‫شما حق‬. ‫ به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد‬،‫ھای درمانی تان‬
‫ برای کسب‬.‫اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد‬
‫( تماس‬800-842-5357 ‫ تماس باشماره‬TTY ‫ )کاربران‬800-722-1471 ‫اطالعات با شماره‬
.‫برقرار نماييد‬
Polskie (Polish):
To ogłoszenie może zawierać ważne informacje. To ogłoszenie może
zawierać ważne informacje odnośnie Państwa wniosku lub zakresu
świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na
kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie
przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub
pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej
informacji we własnym języku. Zadzwońcie pod 800-722-1471
(TTY: 800-842-5357).
Português (Portuguese):
Este aviso contém informações importantes. Este aviso poderá conter
informações importantes a respeito de sua aplicação ou cobertura por meio
do Premera Blue Cross. Poderão existir datas importantes neste aviso.
Talvez seja necessário que você tome providências dentro de
determinados prazos para manter sua cobertura de saúde ou ajuda de
custos. Você tem o direito de obter esta informação e ajuda em seu idioma
e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).
Fa’asamoa (Samoan):
Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau
ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala
atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua
atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei
fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le
aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai
i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua
atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i
ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471
(TTY: 800-842-5357).
Español (Spanish):
Este Aviso contiene información importante. Es posible que este aviso
contenga información importante acerca de su solicitud o cobertura a
través de Premera Blue Cross. Es posible que haya fechas clave en este
aviso. Es posible que deba tomar alguna medida antes de determinadas
fechas para mantener su cobertura médica o ayuda con los costos. Usted
tiene derecho a recibir esta información y ayuda en su idioma sin costo
alguno. Llame al 800-722-1471 (TTY: 800-842-5357).
Tagalog (Tagalog):
Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang
paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon
tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue
Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring
mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang
panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na
walang gastos. May karapatan ka na makakuha ng ganitong impormasyon
at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471
(TTY: 800-842-5357).
ไทย (Thai):
ประกาศนี ้มีข้อมูลสําคัญ ประกาศนี ้อาจมีข้อมูลที่สําคัญเกี่ยวกับการการสมัครหรื อขอบเขตประกัน
สุขภาพของคุณผ่าน Premera Blue Cross และอาจมีกําหนดการในประกาศนี ้ คุณอาจจะต้ อง
ดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกันสุขภาพของคุณหรื อการช่วยเหลือที่
มีค่าใช้ จ่าย คุณมีสิทธิที่จะได้ รับข้ อมูลและความช่วยเหลือนี ้ในภาษาของคุณโดยไม่มีค่าใช้ จ่าย โทร
800-722-1471 (TTY: 800-842-5357)
Український (Ukrainian):
Це повідомлення містить важливу інформацію. Це повідомлення
може містити важливу інформацію про Ваше звернення щодо
страхувального покриття через Premera Blue Cross. Зверніть увагу на
ключові дати, які можуть бути вказані у цьому повідомленні. Існує
імовірність того, що Вам треба буде здійснити певні кроки у конкретні
кінцеві строки для того, щоб зберегти Ваше медичне страхування або
отримати фінансову допомогу. У Вас є право на отримання цієї
інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за
номером телефону 800-722-1471 (TTY: 800-842-5357).
Tiếng Việt (Vietnamese):
Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông
tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua
chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông
báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn
để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có
quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình
miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).