Fillable Pediatric Sleep Study Worksheet

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Pediatric Sleep Study Worksheet

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Page 1 of 3
Weight:
Physician
Physician Address:
City:
State:
ZIP:
Pediatric Sleep Study Worksheet
PH#: 888-511-0401 Website: www.eviCore.com
Patient
Patient Name:
DOB:
Insurance Plan:
Member ID:
Epworth Sleepiness Score (ESS, see page 3 ):
BMI: Height:
MD NPI #: Ordering Physician Name:
Name:
TIN:
a. Complaints and Symptoms: (Check all that apply)
a. Study Requested
b. Duration of Symptoms: How long has the patient been experiencing their symptoms?
One month
< One month. Number of weeks:
Three months
> Six months. Number of months:
b. Has the patient had a comprehensive sleep evaluation by the ordering physician?
Yes No
Repeat Test (If so, what was the original DOS?)
Home Sleep Test (G0399)
Split Night Study (95810)
Polysomnography - Attended (95810)
PAP Titration (95811)
PAP Titration, <6 yrs. old (95783)
Polysomnography, <6 yrs. old (95782)
c. Participating site if a facility based study is authorized.
Disturbed or restless sleep
Difficulty concentrating
Choking during sleep
Bedwetting
Non-ambulatory individual
Enlarged tonsils
High blood pressure
Snoring
Non-restorative sleep
Excessive sweating at night
Gasping during sleep
Hyperactive behavior
Night terrors/ Nightmares
Slow rate of growth
Obesity BMI:
Excessive daytime sleepiness
Morning headaches
Witnessed apnea events
Frequent unexplained arousals
Irritability
Retrognathia
Movement arousals
Paradoxical breathing
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Neck hyperextension during
sleep
Pediatric Sleep Study Worksheet
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5
Yes
No
Yes
No
6
Yes No
Yes
No
Yes
No
Page 2 of 3
Patient Name:
a. Co-morbid Conditions (recent supporting office notes required):
a. Has the PAP machine been used for >2 months?
b. How many nights a week does the patient use their PAP device?
c. How many hours per night does the patient use their PAP device?
d. Has the patient had a mask refit or adjustment?
e. Has the patient reveived instruction on the proper use and case of their PAP equipment?
Lung disease (cystic fibrosis, uncontrolled
asthma, etc.)
Neuromuscular weakness and impaired
respiratory function
Neurodegenerative disorders
Weekly hypnagogic hallucinations
Other:
PAP Compliance for Repeat Studies:
Medications (please list all medications):
a. Has the member had a tonsillectomy and/or adenoidectomy since the prior study?
b. If the member had a tonsillectomy/adenoidectomy, does the member still have
sleep apnea symptoms after the surgery? If so, please list symptoms below
Repeat Study Indication: You may include additional information in section (7)
b. Duration of the Co-morbid Conditions: How long has the patient presented with their co-morbid condition?
Three months
< One month. Number of weeks:
One month
> Six months. Number of months:
c. What was the member's apnea-hypopnea index (AHI or number of times there was low airflow during
sleep), lowest SAO2, and highest PCO2 level on the prior sleep test?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Significant, persistent cardiac arrhythmia
Suspected nocturnal seizures
Cataplexy
Documented signs of narcolepsy
Attention Deficit Hyperactivity Disorder (ADHD)
Pediatric Sleep Study Worksheet
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Score
9
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
Situation Chance of Dozing or Sleeping
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle without a break
Lying down in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch
Doing homework or taking a test
Total score
Additional clinical information that will apply to requested CPT code:
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:
Patient Name:
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Completed 22 June 2021

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