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Medical & Coding Policies
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Out-of-State & Non-Network
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DESCRIPTIONActigraphy refers to the assessment of activity patterns by devices typically placed on the wrist or ankle that record body movement, which is interpreted by computer algorithms as periods of sleep and wake. Sleep/wake cycles may be altered in sleep disorders including insomnia, circadian rhythm sleep disorders, sleep-related breathing disorders, restless legs syndrome, and periodic limb movement disorder. In addition, actigraphy could potentially be used to assess sleep/wake disturbances associated with numerous other diseases or disorders such as attention-deficit/hyperactivity disorder, chronic fatigue syndrome, asthma, Parkinson’s syndrome, post-surgical delirium, stroke, advanced cancer, and intensive care monitoring.Actigraphy refers to the assessment of activity patterns by devices typically placed on the wrist or ankle that record body movement, which is interpreted by computer algorithms as periods of sleep and wake. Sleep/wake cycles may be altered in sleep disorders including insomnia, circadian rhythm sleep disorders, sleep-related breathing disorders, restless legs syndrome, and periodic limb movement disorder. In addition, actigraphy could potentially be used to assess sleep/wake disturbances associated with numerous other diseases or disorders such as attention-deficit/hyperactivity disorder, chronic fatigue syndrome, asthma, Parkinson’s syndrome, post-surgical delirium, stroke, advanced cancer, and intensive care monitoring.
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POLICYActigraphy is considered investigational as a technique to record and analyze body movement, including but not limited to its use to evaluate sleep disorders.
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POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
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POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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POLICY HISTORY7/21/2005: Approved by Medical Policy Advisory Committee (MPAC)8/7/2006: Policy reviewed, no changes 9/18/2007: Policy reviewed, no changes 12/24/2008: Coding updated per the 2009 CPT/HCPCS revisions 8/14/2009: Policy reviewed, no changes 04/20/2011: Policy description updated; policy statement unchanged. Added FEP verbiage to the Policy Exceptions section. Removed deleted CPT code 0089T from the Code Reference section. 03/02/2012: Policy reviewed; no changes. 04/17/2013: Policy reviewed; no changes.
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SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.73
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CODE REFERENCEThis is not an all-inclusive list of non-covered procedure codes.All codes billed for this procedure are considered investigational and not eligible for coverage. Non-Covered Codes
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