Anthem Blue Cross Connecticut MED.00002 Selected Sleep Testing Services Form

This document addresses selected services for the diagnosis of sleep disorders including:

• “Nap” studies
• Actigraphy, including use of static charge sensitive beds
• Diagnostic audio recording, with or without pulse oximetry to document sleep apnea
• Topographic brain mapping
• Acoustic pharyngometry

Note: For criteria related to other sleep testing services, refer to applicable guidelines used by the plan.

Position Statement

Investigational and Not Medically Necessary:

“Nap” studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy.

The following diagnostic tests are considered investigational and not medically necessary:

1. Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea;
2. Topographic brain mapping;
3. Acoustic pharyngometry (Eccovision^™ Acoustic Pharyngometer^®);
4. Actigraphy or static charge sensitive beds.