Actigraphy

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is not applicable for actigraphy because it is considered investigational/experimental. The provider and facility will be liable for payment unless:

• The provider notifies the member that a specific service has been determined by CoOportunity Health to be investigational/experimental; and
• The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
• The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Actigraphy is considered investigational/experimental and is therefore not covered.

Actigraphy is a relatively non-invasive method of monitoring human rest/activity cycles. A small actigraph unit is worn by a patient, usually on the wrist, to measure gross motor activity. The unit continually records the movements it undergoes. The data is later read to a computer where it can be analyzed. Actigraphy testing is based on the assumption that movement is reduced during sleep compared with wakefulness and that activity level can be used as a diagnostic indicator for sleep disorders.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

95803 - Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours
to 14 consecutive days of recording)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.