970 Form

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Medical Policy Carelon (formerly AIM) Sleep Disorder Management CPT, HCPCS and Diagnoses Codes Policy Number: 970 BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies

• Medicare Advantage: Carelon Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923 • Carelon Sleep Disorder Management, #969 • Carelon Advanced Imaging/Radiology, #968
• Carelon Advanced Imaging/Radiology CPT and HCPCS Codes, #900
• Carelon Advanced Imaging of the Heart, #972
• Carelon Advanced Imaging of the Heart CPT, HCPCS and Diagnoses Codes, #971
Table of Contents Medicare Advantage Products ........................................................................................................... 2 Table 1. Bi-Level Positive Airway Pressure (BPAP) Devices CPT and HCPCS Codes ...................... 2 Table 2. Management of Obstructive Sleep Apnea (OSA) Oral Appliances CPT and HCPCS Codes 2 Table 3. Management of Obstructive Sleep Apnea (OSA) using Auto-Titrating Positive Airway Pressure (APAP) and Continuous Positive Airway Pressure (CPAP) Devices CPT and HCPCS Codes ................................................................................................................................................ 3 Table 4. Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT) CPT and HCPCS Codes .................................................................................................................... 3 Table 5. Polysomnography and Home Sleep Testing CPT and HCPCS Codes ................................. 3 Table 6. Management of Obstructive Sleep Apnea using Implanted Hypoglossal Nerve Stimulators CPT and HCPCS Codes .................................................................................................................... 4 The following codes may not be all inclusive. ..................................................................................... 4 Policy History ..................................................................................................................................... 4 Disclaimer: ......................................................................................................................................... 4

Commercial Products The following CPT and HCPCS codes are in-scope under the Carelon Sleep Disorder Management Program for Commercial Managed Care (HMO and POS) and Commercial PPO and EPO. For medical necessity criteria, see Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder.

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Medicare Advantage Products The following CPT and HCPCS codes are in-scope under the Carelon Sleep Management Program for Medicare HMO and PPO. For medical necessity criteria, see Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder.

Table 1. Bi-Level Positive Airway Pressure (BPAP) Devices CPT and HCPCS Codes
The following codes may not be all-inclusive.

HCPCS Codes Code Description E0470 Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with non-invasive interface (nasal or facial mask) E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with non-invasive interface (nasal or facial mask) E0561 Humidifier, non-heated, used with positive airway pressure device E0562 Humidifier, heated, used with positive airway pressure device E1399 Durable medical equipment, miscellaneous A4604 Tubing with heating element A7027 Combination Oral/Nasal Mask used with positive airway pressure device, each A7028 Oral Cushion, Replacement for Combination Oral/Nasal Mask, each A7029 Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair A7030 Full Face Mask used with positive airway pressure device, each A7031 Face Mask Cushion, Replacement for Full Face Mask A7032 Replacement Cushion for Nasal Application Device A7033 Replacement Pillows for Nasal Application Device, pair A7034 Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap A7035 Headgear A7036 Chinstrap A7037 Tubing A7038 Filter, disposable A7039 Filter, non-disposable A7044 Oral Interface for Positive Airway Pressure Therapy A7045 Replacement Exhalation Port for PAP Therapy A7046 Water chamber for humidifier, replacement, each

Table 2. Management of Obstructive Sleep Apnea (OSA) Oral Appliances CPT and HCPCS Codes The following codes may not be all-inclusive.

CPT Codes Code Description
0964T Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mechanism 0965T Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, non-fixed hinge mechanism 0966T Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, fixed hinge mechanism

HCPCS Codes Code Description
E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, custom fabricated, includes fitting and adjustment K1027 Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment ICD-10 Diagnoses Codes

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ICD-10 Code Description G47.33 Obstructive sleep apnea (adult) (pediatric)

The following HCPCS code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity and Medicare HMO Blue and Medicare PPO Blue:

HCPCS Codes
HCPCS Codes Code Description E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, prefabricated, includes fitting and adjustment

Table 3. Management of Obstructive Sleep Apnea (OSA) using Auto-Titrating Positive Airway Pressure (APAP) and Continuous Positive Airway Pressure (CPAP) Devices CPT and HCPCS Codes The following codes may not be all-inclusive.

HCPCS Codes Code Description E0561 Humidifier, non-heated, used with positive airway pressure device E0562 Humidifier, heated, used with positive airway pressure device E0601 Single level continuous positive airway pressure device or auto-titrating continuous positive airway pressure E1399 Durable medical equipment, miscellaneous A4604 Tubing with heating element A7027 Combination Oral/Nasal Mask used with positive airway pressure device, each A7028 Oral Cushion, Replacement for Combination Oral/Nasal Mask, each A7029 Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair A7030 Full Face Mask used with positive airway pressure device, each A7031 Face Mask Cushion, Replacement for Full Face Mask A7032 Replacement Cushion for Nasal Application Device A7033 Replacement Pillows for Nasal Application Device, pair A7034 Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap A7035 Headgear A7036 Chinstrap A7037 Tubing A7038 Filter, disposable A7039 Filter, non-disposable A7044 Oral Interface for Positive Airway Pressure Therapy A7045 Replacement Exhalation Port for PAP Therapy A7046 Water chamber for humidifier, replacement, each

Table 4. Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT) CPT and HCPCS Codes The following codes may not be all inclusive.

CPT codes Code Description
95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

Table 5. Polysomnography and Home Sleep Testing CPT and HCPCS Codes The following codes may not be all inclusive.

CPT codes Code Description
95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional

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parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist 95800 Sleep study, unattended simultaneous recording heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time 95801 Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation and respiratory analysis (e.g., by airflow or peripheral arterial tone) 95806 Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e. g., thoracoabdominal movement) 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist 95808 Polysomnography; sleep staging with 1–3 additional parameters of sleep, attended by a technologist 95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95811 Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist HCPCS Codes Code Description G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels

Table 6. Management of Obstructive Sleep Apnea using Implanted Hypoglossal Nerve Stimulators CPT and HCPCS Codes The following codes may not be all inclusive.

CPT codes Code Description
64568 Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator *** Requires prior authorization for obstructive sleep apnea (G47.33) 64582 Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array 64583 Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator 64584 Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array

Policy History 2/2026 Added 64568 and indicated prior authorization is required for obstructive sleep apnea (G47.33) 10/2025 0966T, 0964T, 0965T were added. Effective 10/1/2025. K10727 added. Effective 10/1/2025. 3/2023 AIM Specialty Health changed its name to Carelon Medical Benefits Management. 9/2022 Hypoglossal nerve stimulator codes 64582; 64583; 64584 were added. Effective 9/11/2022. 9/2019 New document #970 issued. Effective 9/1/2019.

Disclaimer:
Coverage is subject to applicable benefit contract. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Member’s medical records must document that services are medically necessary for the care provided. BCBS MA maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available upon request. Failure to produce the requested information may result in denial or retraction of payment.