![]() Codes requiring a 7th character are represented by "+":ĬPT codes covered if selection criteria are met: Information in the below has been added for clarification purposes. Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code CPB 0004 - Obstructive Sleep Apnea in Adults.neurologic disorders other than narcolepsy (e.g., dementia (including Alzheimer's disease and dementia with Lewy bodies) and Parkinson's disease).evaluation of the effectiveness of modafinil therapy in narcolepsy.evaluation of common, uncomplicated or noninjurious parasomnias, such as typical disorders of arousal, bruxism, enuresis, nightmares or sleep talking.attention-deficit/hyperactivity disorder.MSLT and MWT are considered experimental and investigational for all other indications because its effectiveness for indications other than the ones listed in Section I have not been established, including (not an all-inclusive list):.Single nap studies because a full MSLT or MWT is required for accurate diagnosis of narcolepsy.Home MSLT because home MSLT has not been proven to be equivalent to formal MSLT performed in a sleep laboratory.The following tests and procedures are considered experimental and investigational: The patient is suspected to have narcolepsy but earlier MSLT or MWT evaluation did not provide polygraphic confirmation.The initial test is affected by extraneous circumstances or when study conditions were not present during initial testing or. ![]() The initial test was invalid or uninterpretable or.Repeat MSLT and MWT tests are considered not medically necessary, unless:.For evaluation of persons with suspected idiopathic hypersomnia to help differentiate idiopathic hypersomnia from narcolepsy.For evaluation of symptoms of narcolepsy, to confirm the diagnosis or.This Clinical Policy Bulletin addresses multiple sleep latency test (MSLT) and maintenance of wakefulness test (MWT).Īetna considers the multiple sleep latency test (MSLT) and maintenance of wakefulness test (MWT) medically necessary for either of the following 2 indications: Number: 0330 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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