What documentation does Anthem require for CPT 95810?

Sleep evaluation documentation; Validated sleep questionnaire; Medical history; Prior HST results if performed

How much does Medicare pay for CPT 95810 in 2026?

In 2026, the national Medicare allowable for CPT 95810 is $673.70 in an office setting and $673.70 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 95810?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 95810

Laboratory-assisted sleep studies including polysomnography for sleep apnea diagnosis · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for in-lab polysomnography. Medically necessary after failed or inconclusive HST, for patients with significant comorbidities, suspected non-OSA sleep disorders, and CPAP titration. Split-night study preferred when diagnostic AHI is elevated. Home sleep testing is required as first-line for uncomplicated suspected OSA.

Documentation checklist

✓Sleep evaluation documentation
✓Validated sleep questionnaire
✓Medical history
✓Prior HST results if performed

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 95810

Office (non-facility)

$673.70

Facility

$673.70

Total RVUs (office)

20.17

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 95810 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Sleep evaluation documentation, Validated sleep questionnaire, Medical history….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 95810?: Yes. Anthem requires prior authorization for CPT 95810 (Laboratory-assisted sleep studies including polysomnography for sleep apnea diagnosis) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 95810?: Sleep evaluation documentation; Validated sleep questionnaire; Medical history; Prior HST results if performed
How much does Medicare pay for CPT 95810 in 2026?: In 2026, the national Medicare allowable for CPT 95810 is $673.70 in an office setting and $673.70 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 95810?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

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CPT 95810 prior authorization by payer

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