Does G47.9 require prior authorization?

No, G47.9 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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`G47.9`, Sleep disorder, unspecified

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.
Home sleep tests (G0398, G0399, G0400) are covered when performed in conjunction with a comprehensive sleep evaluation and the patient has a high pretest probability of moderate to severe obstructive sleep apnea (OSA).
Polysomnography (CPT 95808, 95810, 95811) is covered when performed in a facility-based sleep study laboratory (not in the home or a mobile facility).
Testing related to suspected narcolepsy (including Multiple Sleep Latency Test, CPT 95805) is covered when clinic documentation shows narcolepsy symptoms are severe enough to interfere with the patient’s health and well-being.

20 Active Policies

CGS-J15-L36902, Polysomnography and Other Sleep Studies

J15

CGS-J18-L36902, Polysomnography and Other Sleep Studies

J18

WPS-J5-L36839, Polysomnography and Other Sleep Studies

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

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G47.9, Sleep disorder, unspecified