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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.67 Sleep Studies : Multiple Sleep Latency Test (MSLT)
Multiple sleep latency test (procedure code 95805) is limited to one per day and two per rolling year by any provider, and is restricted to the following diagnosis codes:
Claims denied for more than two times per year may be appealed with documentation of medical necessity.
Documentation of MSLT must be maintained in the client’s medical record at the sleep facility and include a hard copy or electronic copy of four to five 20-minute recordings of sleep-wake states and stages spaced at two-hour intervals throughout the day, taking approximately seven to nine hours to complete. In addition, documentation must include the physiological recordings typically made during daytime testing. These typically include:
Documentation must also include the technologist’s analysis and report, the client’s subjective report, and the influence of intervention applied during the night.
Interpretation and treatment recommendations must be completed by a sleep specialist. The physician’s interpretation and report must include inspection of the entire recording, examination of the technologist’s analysis and observations, and integration of the information gathered from all physiological systems. Documentation of the interpretation must be maintained in the sleep facility and by the interpreting physician.
MSLT procedure code 95805 must be performed in conjunction with polysomnography procedure code 95782, 95783, 95808, 95810, or 95811. Polysomnography must be performed on the date before MSLT. MSLT that is not performed in conjunction with polysomnography will be denied, but may be considered on appeal with documentation that explains why the polysomnography did not occur.

Texas Medicaid & Healthcare Partnership
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