Anthem Blue Cross and Blue Shield Virginia policy
Sleep Studies and Related Bundled Services and Supplies – Professional
Sleep Studies and Related Bundled Services and Supplies – Professional is a public Anthem Blue Cross and Blue Shield Virginia policy (policy C-09009, effective Mar 1, 2023). It lists 12 CPT or HCPCS codes, 12 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- C-09009
- Effective
- Mar 1, 2023
- Line of business
- Commercial
- States
- VA
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 95782 | On the list | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Policies naming 95782 |
| 95783 | On the list | 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 | Policies naming 95783 |
| 95800 | On the list | Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time | Policies naming 95800 |
| 95801 | On the list | Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) | Policies naming 95801 |
| 95806 | On the list | Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory | Policies naming 95806 |
| 95807 | On the list | Sleep Study, Attended | Policies naming 95807 |
| 95808 | On the list | Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist | Policies naming 95808 |
| 95810 | On the list | Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist | Policies naming 95810 |
| 95811 | On the list | 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 v | Policies naming 95811 |
| G0398 | On the list | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart r | Policies naming G0398 |
| G0399 | On the list | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow | Policies naming G0399 |
| G0400 | On the list | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels | Policies naming G0400 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list