Clarification of Polysomnogram Requirements

There are no new updates to the policy.  This is to clarify requirements for polysomnogram per Clinical Coverage Policy 5A, section 5.3.11.

• Where a polysomnogram is required, the results are required ONLY for initial authorizations.
• Policy does not specify the age of the polysomnogram. Best practices would presume that it be a recent study.
• Reauthorization requests do NOT require a repeat polysomnogram.
• Changing of equipment when a repair is needed does NOT require a repeat polysomnogram.
• Replacement of equipment after the lifetime expectancy is reached does NOT require a repeat polysomnogram.

All criteria for medical necessity and prior approval remain unchanged. Please see Clinical Coverage Policy 5A, section 5.3.11 for details.