Polysomnography (PSG) and a multiple sleep latency test performed on the day after the PSG may be considered medically necessary in the evaluation of suspected narcolepsy or idiopathic hypersomnia.
PSG may be medically necessary when evaluating patients with parasomnias when there is a history of sleep-related injurious or potentially injurious disruptive behaviors.
PSG may be medically necessary when a diagnosis of periodic limb movement disorder is considered when there is:
A complaint of repetitive limb movement during sleep by the patient or an observer; and
No other concurrent sleep disorder; and
At least one of the following is present:
Frequent awakenings; or
Fragmented sleep; or
Difficulty maintaining sleep; or
Excessive daytime sleepiness.
PSG for the diagnosis of periodic limb movement disorder is considered not medically necessary when there is concurrent untreated obstructive sleep apnea, restless legs syndrome, narcolepsy, or rapid eye movement sleep behavior disorder.
PSG is considered investigational for the diagnosis of non-respiratory sleep disorders not meeting the criteria above, including but not limited to nightmare disorder, depression, sleep-related bruxism, or noninjurious disorders of arousal.