`95808` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 95808

74 of 74 payer prior-auth lists that name 95808 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Federal Employee Program (FEP)	AZ	prior auth under conditions	FEP Standard and Basic only	Sep 1, 2026	Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Aetna	Commercial	All	prior auth required	Not required for Student Health or Allina Health \| Aetna plans; Not required inpatient, in the ER or in observation	Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required	Not required for Student Health or Allina Health \| Aetna plans; Not required inpatient, in the ER or in observation	Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Feb 18, 2013	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Feb 18, 2013	Master Precertification List (For Health Care Providers)
Cigna	Sleep	All	prior auth required		Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Cigna	Sleep	All	prior auth required		Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Sleep Management
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required		Oct 1, 2026	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required	eviCore-managed	Jan 1, 2025	Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required	vendor review only eviCore in IL/MI/OH/NY/WI	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required	vendor review only eviCore in IL/MI/OH/NY/WI	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Apr 1, 2023	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Exchange	MI	prior auth required	Contact eviCore for PA	Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	Exchange	TX	prior auth required	place of service 12	May 20, 2020	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required	vendor review only eviCore in IL/MI/OH/NY/WI	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required	vendor review only eviCore in IL/MI/OH/NY/WI	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required		Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare West commercial plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth under conditions	site of care: site of service reviewed	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth under conditions	not in NY	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026

Payer coverage policies that name 95808

95808 appears in 23 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Capital Blue Cross, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT) (0330)	listed, no stance (range 95808-95811)	May 20, 2026	payer document
Aetna	Myalgic Encephalomyelitis - Chronic Fatigue Syndrome (ME/CSF) (0369)	covered if criteria are met (range 95808-95811)	May 20, 2026	payer document
Aetna	Obstructive Sleep Apnea in Adults (0004)	covered if criteria are met	Oct 6, 2026	payer document
Aetna	Obstructive Sleep Apnea in Children (0752)	covered if criteria are met	Oct 30, 2025	payer document
Aetna	Positive Pressure Ventilation (0452)	listed, no stance (range 95808-95811)	Jul 1, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Sleep Disorders (L.2.01.415)	not covered		payer document
Blue Cross NC	Sleep Apnea: Diagnosis and Medical Management	listed, no stance	Mar 1, 2026	payer document
Blue Shield of California	Polysomnography for Non-Respiratory Sleep Disorders (2.01.99)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Polysomnography for Non-Respiratory Sleep Disorders (CAM 20199)	listed, no stance	Aug 1, 2026	payer document
Capital Blue Cross	Polysomnography for Non‒Respiratory Sleep Disorders (MP 2.335) Procedure codes	covered if criteria are met	Feb 1, 2026	payer document
Centene	Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248)	covered if criteria are met		payer document
Cigna	Electroencephalography (0521)	not covered	Feb 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Diagnosis of Obstructive Sleep Apnea Syndrome (MED204.005) CPT Codes 94660, 94762, 95782, 95783, 95800, 95801, 95805, 95806, 95807,	listed, no stance	Oct 1, 2026	payer document
UnitedHealthcare	Sleep Studies (2026T0334SS)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sleep Studies (CS098.AE)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for Idaho Only) (CS098ID.D)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for Kansas Only) (CS098KS.03)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for Kentucky Only) (CS098KY.10)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for Nebraska Only) (CS098NE.C)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for New Jersey Only) (CS098NJ.AB)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for New Mexico Only) (CS098NM.D)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for North Carolina Only) (CSNCT0334.09)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sleep Studies (for Ohio Only) (CS098OH.D)	listed, no stance	Jul 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Mar 1, 2025: conditions changed, UnitedHealthcare Community Plan
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Feb 19, 2025: PA removed, Molina Healthcare of Texas

Medicaid fee-for-service

Prior authorization required or conditional in NE, WA.

AZ: $666.87 (outpatient_hospital), effective Oct 1, 2021
CO: $216.68 (chp_plus, non-facility), effective Jul 1, 2026
FL: $335.11 (physician), effective Jan 1, 2026
IL: $369.43 (practitioner), effective Apr 1, 2024
IN: $64.11 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $243.55 (default, Exempt Physician), effective Jul 1, 2024
KY: $328.73 (physician, facility), effective Jan 1, 2026
LA: $497.88 (professional), effective Feb 1, 2013
MA: $60.68 (physician_medicine), effective May 1, 2024
MS: $403.67 (comprehensive), effective Jul 1, 2026
ND: $481.38 (physician), effective Aug 1, 2026
NE: $766.10 (physician, non-facility), effective Jul 1, 2026
NY: $533.69 (physician_medicine, facility), effective Jul 1, 2026
OH: $342.78 (physician), effective Jan 1, 2024
OK: $359.79 (physician, non-facility), effective Jul 1, 2026
TX: $393.47 (miscellaneous_other_professionals_portable_x_ray_radiologica, Miscellaneous Other Professionals - Portable X-Ray, Radiological Lab, Physiological Lab, non-facility), effective Sep 1, 2025
VA: $373.27 (medical), effective Jul 1, 2026
VT: $666.78 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $271.36 (physician, facility), effective Jul 1, 2026
WY: $379.77 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

95808 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 95808

Payer coverage policies that name 95808

Recent prior-auth changes

Medicaid fee-for-service

`95808` CPT® code: payer coverage and prior authorization