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Clarification: Sleep Study Procedures for Members 17 Years of Age and Younger

Date: 07/07/25

Superior HealthPlan does not require prior authorization for members 17 years of age and younger for sleep study procedures for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter from Superior HealthPlan.

Below are the Current Procedural Terminology (CPT) codes for reference.

Members 17 years of age and younger do not require prior authorization for the following procedures for Medicaid, CHIP and Ambetter:

CPT Codes

Description

95803

Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)

95805

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

95807

Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist

95808

Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist

95810

Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

95811

Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist

Members of all ages do not require prior authorization for the following procedures for Medicaid, CHIP and Ambetter:

CPT Codes

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 parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

95800

Sleep Study, Unattended

95801

Sleep Study, Unattended with Analysis

95806

Sleep Study (Vent-Resp-ECG-O2 Sat, Unattended)

G0398

Home Sleep Test, Type II Portable

G0399

Home Sleep Test, Type III Portable

G0400

Home Sleep Test, Type IV Portable

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.