Clarification of Polysomnogram Requirements


There are no new updates to the policy.  This is to clarify requirements for polysomnogram per Clinical Coverage Policy 5A, section 5.3.11.

 

  • Where a polysomnogram is required, the results are required ONLY for initial authorizations.
  • Policy does not specify the age of the polysomnogram. Best practices would presume that it be a recent study.
  • Reauthorization requests do NOT require a repeat polysomnogram.
  • Changing of equipment when a repair is needed does NOT require a repeat polysomnogram.
  • Replacement of equipment after the lifetime expectancy is reached does NOT require a repeat polysomnogram.

 

All criteria for medical necessity and prior approval remain unchanged. Please see Clinical Coverage Policy 5A, section 5.3.11 for details.