Does G47.61 require prior authorization?

No, G47.61 does not require prior authorization (high confidence). Covered without prior authorization.

`G47.61`, Periodic limb movement disorder

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.

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.
Outpatient sleep studies that meet the reasonable and necessary clinical criteria in Novitas LCD L35050 are covered.
Home sleep testing performed with a WatchPAT device should be billed with CPT code 95800 or 95801.
Actigraphy may be reported with CPT code 95803 to document CPAP coverage under the applicable NCD or as follow-up CPAP administration when accepted by the DME contractor.

CGS-J15-L36902, Polysomnography and Other Sleep Studies

J15

CGS-J18-L36902, Polysomnography and Other Sleep Studies

J18

A56903, Billing and Coding: Polysomnography and Other Sleep Studies

WPS-J5-L38528, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea

Ask Backwork about documentation requirements, denial risks, or coverage in your state.