Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT) (CPB 0330, reviewed 2026-05-20)

By 2026-05-20: Billing team must implement the following changes to align with updated Aetna policy: (1) Update billing system logic to allow CPT 95805 (MSLT/MWT) ONLY when primary diagnosis is G47.411-G47.429 (narcolepsy) OR G47.10-G47.19 (hypersomnia) with documented clinical suspicion of narcolepsy for differential diagnosis; (2) Deny or request medical records review for CPT 95805 claims with secondary diagnoses including F90.0-F90.9 (ADHD), G47.33 (OSA), G47.20-G47.29 (circadian disorders), F51.01/F51.03/F51.09 (insomnia), G20-G21 (Parkinson's), G30 (Alzheimer's), G31.83 (Lewy body dementia), G25.81 (RLS), and F01-F03 (other dementias); (3) Add clinical documentation requirement to encounter forms: providers must document whether repeat MSLT/MWT has invalid/uninterpretable prior test, extraneous circumstances affecting initial test, or suspected narcolepsy without prior polygraphic confirmation; (4) Implement hard stop rule in billing system to reject home-based MSLT claims (add modifier or billing note field to identify setting); (5) Update prior authorization templates and denial reason codes to specifically cite CPB 0330 exclusions for non-covered indications. Providers must document medical necessity justifying the specific indication. Claims submitted without alignment to these criteria will be denied. Coordinate with provider education on scope of covered testing.