Sleep Medicine Prior Authorization and Denial Guide

Home sleep apnea testing step-therapy requirements, polysomnography prior authorization criteria, multiple sleep latency test sequencing rules, CPAP and BiPAP compliance requirements, and oral appliance therapy coverage. Grounded in UHC Policy 2026T0334RR, Cigna eviCore sleep guidelines, CMS NCD 240.4, and AASM Clinical Practice Parameters for diagnostic testing and PAP therapy.

HSAT vs. PSG: most commercial payers require HSAT (CPT 95800, 95806) as the initial diagnostic study for adults with suspected OSA who do not have significant comorbidities. In-lab PSG (CPT 95808, 95810) requires prior authorization when the indication is anything other than uncomplicated OSA — narcolepsy workup, parasomnias, RLS/PLMD, non-restorative sleep with atypical features, or HSAT technically inadequate. HSAT studies reporting AHI ≥5 confirm OSA; studies with AHI <5 do not rule out OSA in patients with high pre-test probability, and in-lab PSG should be recommended.

CPAP and BiPAP prior authorization: Medicare NCD 240.4 requires AHI ≥15 on a qualifying sleep study, or AHI ≥5 with documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, or cardiovascular disease. Commercial payer criteria are similar. The 90-day compliance documentation requirement applies to both Medicare and most commercial payers — CPAP must be used for ≥4 hours/night on ≥70% of nights in any 30-day period during the first 90 days of therapy. Multiple Sleep Latency Testing (MSLT, CPT 95805) for narcolepsy requires prior authorization and must be performed the day after an in-lab PSG that excludes other sleep disorders — MSLT results are not interpretable without a preceding PSG.

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