RE: HOME SLEEP TEST
IMPACTED PLANS: MEDICAID, HARP & HIV SNP
TO: MEDICAID MANAGED CARE PROVIDERS
Effective December 1, 2024 onwards, per New York State (NYS) Medicaid guidance, MetroPlusHealth will begin coverage and reimbursement of Home Sleep Test (HST) if the Medicaid member meets the coverage criteria. HST, also known as Unattended Sleep Study or Home Sleep Apnea Test (HSAT), is intended to assist in diagnosing sleep disorder breathing conditions in the home setting, when medically appropriate.
NYS Medicaid HST Coverage Criteria and Limitations
- For members who would experience difficulty traveling to a sleep lab for sleep test (polysomnography) due to mobility issues.
- For eligible members 18 and older who meet the criteria.
- HST can only be billed once per year,
- If a repeat is needed before the one-year, credible medical evidence is needed.
- A repeat HST may be indicated for the following scenarios:
- If the first study was inadequate because of equipment failure
- Member was unsure how to operate the HST equipment correctly
- Did not sleep for a sufficient amount of time to be clinically diagnosed
The American Academy of Sleep Medicine (AASM) does not recommend the use of HST for children who have been diagnosed with Obstructive Sleep Apnea (OSA) due to the inability to validate OSA in children.
Providers should use their clinical judgement to determine if a HST is a medically appropriate alternative. HST raw data must also be reviewed and interpreted by a Sleep Medicine specialist who is either board-certified or board-eligible in Sleep Medicine.
*NYS Billing Codes and Reimbursement Guidelines
| CPT Code | Modifier | CPT Code Description |
|---|---|---|
| *95800 | Sleep Study, unattended, simultaneous recordings; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time. | |
| 95800 | TC | Physician provides the test only. |
| 95800 | 26 | Physician only interprets the results. |
- Do not bill (CPT) code “95800”, in conjunction with CPT codes “93041” through “93227”, “93228”, “93229”, “93268” through “93272”, “95801”, “95803”, and “95806”.
*Note:CPT code 95800 is bundled under one rate which includes cost of equipment, the test, and interpreting results.
If you have any questions regarding this memo, please contact MetroPlusHealth at: ProviderRelationsOps@metroplus.org.