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.