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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 ∞ Clicking this icon returns you to the hyperlinks menu above. 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 Page | 2 of 15 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 Page | 3 of 15 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 Page | 4 of 15 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 Page | 6 of 15 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. Page | 7 of 15 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. Page | 9 of 15 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). Page | 10 of 15 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 Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2017 Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member 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 Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Premera: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Email [email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue 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).