A Review of TRICARE Sleep Study Coverage

According to TRICARE, sleep studies and polysomnography refer to the continuous simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours with physician review, interpretation, and report. The studies are performed to diagnose a variety of sleep disorders and to evaluate a patient’s response to therapies such as nasal continuous positive airway pressure (NCPAP).

Polysomnography is distinguished from sleep studies by the inclusion of sleep staging, which is defined to include a 1-4 lead electroencephalogram (EEG), electro-oculogram (EOG), and a submental electromyogram (EMG).

One of the following symptoms must be present for a sleep study or polysomnography to be authorized:

• Excessive daytime sleepiness
• Falling asleep while driving/eating/in the midst of conversation
• Witnessed episodes of apnea

OR at least two of the following symptoms must be present:

• Snoring
• Morning headaches
• Hypertension
• Fatigue
• Difficulty concentrating
• Poor work performance
• Impotence
• Parasomnias (abnormal sleep behavior, such as bruxism, sleepwalking, enuresis and seizure disorder evaluations when the distinction between seizure activity and other forms of sleep disturbance is uncertain)
• Narcolepsy (refers to a syndrome characterized by abnormal sleep tendencies, including excessive daytime sleepiness, disturbed nocturnal sleep and pathological manifestation of rapid eye movement sleep. Related diagnostic testing, e.g., Multiple Sleep Latency Test – CPT Code 95805, is covered if the patient has inappropriate sleep episodes, e.g., while driving, in the midst of a conversation, amnesic episodes or continuous agonizing drowsiness.)

Diagnostic testing can be covered only if the patient has the symptoms or complaints of one of the conditions listed below:

• Narcolepsy
• Obstructive Sleep Apnea Syndrome (OSAS)
• Impotence
• Parasomnias, which is abnormal sleep behavior, such as bruxism, sleepwalking, enuresis, and seizure disorder evaluations when the distinction between seizure activity and other forms of sleep disturbances is uncertain.

Claims for diagnostic sleep studies are processed and paid as outpatient services. Patients who undergo the testing are not considered inpatients, although they may come to a facility in the evening for testing and then leave after their tests are over.

There are a variety of sleep study services that are not covered by TRICARE, including:

• Electrosleep therapy
• Study, grant, or research programs
• Unattended sleep studies performed in the home
• Sleep testing is not indicated for patients whose complaint is of short duration or for patients who do not experience functional disability during the day.
• Diagnostic testing that is duplicative of previous testing done by the attending physician, to the extent the results are still pertinent

Payment may not be made for diagnostic sleep testing of the conditions listed below. These conditions can be diagnosed through other, more appropriate means:

• Drug dependency
• Hypersomnia (pathologically excessive sleep)
• Insomnia
• Night terrors or dream anxiety attacks
• Nocturnal myoclonus (muscle jerks)
• Restless leg syndrome
• Shift work and schedule disturbances
• Migraine headaches
• Documented episodes of cataplexy
• Sleep studies, polysomnography, and diagnostic testing performed in the home
• Somnoplasty system for obstructive sleep apnea

Split-Night Sleep Study Coverage

A split-night sleep study polysomnography is conducted when moderate or severe sleep apnea has been discovered or strongly suspected during the first part of the night’s study. The second half of the night is used for CPAP titration. Providers performing a sleep study polysomnography are required to perform the study in one clinical visit. This includes evaluating the presence of sleep apnea, then titrating and adjusting CPAP. Providers should submit the appropriate claim form with the appropriate CPT code for this service.

TRICARE covers a split-night sleep study for beneficiaries who meet one of the following criteria:

• Apnea/Hypopnea Index (AHI) greater than or equal to 15 events per hour
• AHI greater than or equal to 5 and less than or equal to 14 events per hour with any of the following documented symptoms:
  • Daytime sleepiness
  • Impaired cognition
  • Mood disorders
  • Insomnia
  • Documented hypertension
  • Ischemic heart disease
  • History of stroke
  • Snoring
  • Observed apnea

In some cases, providers have sent a patient home after he/she met one of the criteria and had them return another night to be titrated. The providers then submit the bill and request a second night study. A second study for titration is not covered when performed in two separate visits unless extenuating circumstances prevented all services from being performed in one clinical visit. A new authorization request must be submitted prior to the second study, which must demonstrate evidence of an extenuating circumstance. The request for a second study goes to the Medical Director for approval.

If the patient does not meet the criteria for the split night study, a polysomnography (sleep staging study) may be performed. In this case, the following CPT codes may apply:

• 95808 – Sleep staging with 1-3 additional parameters of sleep.
• 95810 – Sleep staging with 4 or more additional parameters of sleep.

In these cases, there is no need to titrate the patient or adjust the CPAP and the provider should bill TRICARE using an appropriate CPT code.

For further information regarding sleep studies and polysomnography, refer to TRICARE Policy Manual, Chapter 7, Section 19.1, at www.tricare.mil orcall 1-888-TRIWEST (1-888-874-9378).