Does G47.411 require prior authorization?

No, G47.411 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`G47.411`, Narcolepsy with cataplexy

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

If a sleep study is performed for less than six hours, bill with modifier 52 and report the appropriately reduced original charge.
Medical records must document the signs, symptoms, or complaints demonstrating the indication for sleep testing; if the patient is admitted, documentation must explicitly support inpatient admission and indications.
Persuasive medical evidence of medical necessity must be provided when additional tests beyond usual limits (e.g., >1 HST/year, >2 PSG/year, >3 MSLT naps) are claimed.
MSLT (CPT 95805) includes all naps done in a single day; only one unit of CPT 95805 should be submitted for that day's MSLT.

Key Coverage Criteria

Diagnostic polysomnography or other sleep testing is covered when the patient has symptoms or complaints of one of the conditions listed in LCD L36839.
A single polysomnogram (PSG) with EEG is ordinarily sufficient and covered to evaluate and diagnose suspected obstructive sleep apnea (OSA).
Diagnosis of narcolepsy is ordinarily confirmed by up to three Multiple Sleep Latency Test (MSLT) naps; MSLT (CPT 95805) performed appropriately is covered for this indication.
Psychiatric/psychological services are covered when there is a reasonable expectation that withdrawing treatment would cause the patient's condition to deteriorate, relapse, or require hospitalization.
CORF social and psychological services are covered when indicated and may be provided by qualified social workers (minimum BS) or psychologists (minimum Master’s level).
Psychiatric diagnostic procedures may be billed once per day and are covered at the outset of an illness or suspected illness, or again for a new episode after a hiatus or on (re)admission for complications of the underlying condition.

20 Active Policies

CGS-J15-L36902, Polysomnography and Other Sleep Studies

J15

CGS-J15-L34353, Outpatient Psychiatry and Psychology Services

J15

CGS-J18-L34353, Outpatient Psychiatry and Psychology Services

J18

CGS-J18-L36902, Polysomnography and Other Sleep Studies

J18

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G47.411, Narcolepsy with cataplexy