Fillable MSLT/MWT 95805 Worksheet

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MSLT/MWT 95805 Worksheet

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Page 1 of 3
Patient
Physician
Repeat Test (if repeat, what was the original DOS?)
Multiple Sleep Latency Test (MSLT)
Maintenance of Wakefulness Test (MWT)
Patient Name:
DOB:
Physician Address:
City: State: ZIP:
Insurance Plan: Member ID:
Epworth Sleepiness Score (ESS, see page 3 ):
BMI: Height: Weight:
Clinical Information: (Check all that apply)
a. Complaints and Symptoms
b. Duration of Symptoms: How long has the patient been experiencing their symptoms?
a. Study Requested
TIN:
b. Participating site if a facility based study is authorized.
Name:
Excessive Daytime Sleepiness
Hypnagogic hallucinations
Automatic behaviors
Waking up from sleep often
MSLT/MWT 95805 Worksheet
PH#: 888-511-0401 Website: www.eviCore.com
MD NPI #:Ordering Physician Name:
< One month. Number of weeks:
Three Months
One Month
Daily recurrent naps or lapses into sleep
Hypnopompic hallucinations
Sleep paralysis
Idiopathic hypersomnia
Patient is a shift worker
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Cataplexy (sudden loss of muscle
tone occurring in association with
intense emotions, e.g., crying or
laughing)
MSLT/MWT 95805 Worksheet
3
Yes
No
Yes
No
N/A
Yes
No
Yes
No
Yes No
4
5
Yes
No
6
Page 2 of 3
b. IF YES, please answer the questions below. IF NO, skip to section (4).
Did the previous study document OSA?
Medications (please list all medications):
Has the OSA been corrected with therapy?
If OSA is being treated with PAP, is there use of PAP for an average of 4
hours per night for 70% of nights?
Did the study document any other sleep disorders besides OSA?
Have the sleep disorders (other than OSA) been adequately treated?
Patient Name:
Additional clinical information that will apply to requested CPT code:
Repeat Study Indication: Did the member have a previous MSLT which was
inconclusive for narcolepsy or idiopathic hypersomnia?
a. Previous Study: Has the patient had a previous diagnostic sleep study?
Yes
No, however an attended sleep study is planned in conjunction with this procedure.
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
7
Score
8
Date:
Page 3 of 3
Physician Signature:
0 = Would never doze or sleep
1 = Slight chance of dozing or sleeping
2 = Moderate change of dozing or sleeping
3 = High chance of dozing or sleeping
Epworth Sleepiness Scale: Must be completed for authorization
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
This refers to your usual way of life in recent times. Even if you have not done some of these things
recently try to imagine how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopped for a few minutes in traffic while driving
Total score
Situation Chance of Dozing or Sleeping
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle for an hour or more
MSLT/MWT 95805 Worksheet
Patient Name:
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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MSLTMWT 95805 Worksheet

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Completed 22 June 2021

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