Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Effective Date:
February 1, 2021
Issued Date:
February 1, 2021
Last Revision Date:
October 2020
Annual Review:
October 2020

This policy version was replaced on October 1, 2021. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Actigraphy is a non-invasive method of monitoring rest, activity cycles, and circadian rhythms by assessing body movement over a period of time. The devices are typically placed on the wrist or ankle. Various computer algorithms then interpret the information as periods of sleep and wake. Sleep/wake cycles may be altered in sleep disorders such as 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 might also be used to measure the level of physical activity.

Actigraphic devices are typically placed on the non-dominant wrist with a wristband and are worn continuously for at least 24 hours. Activity is usually recorded for a period of three days to two weeks, but can be collected continuously over extended time periods with regular downloading of data onto a computer. The activity monitors may also be placed on the ankle for the assessment of restless leg syndrome, or on the trunk to record movement in infants. Data on patient bed times (lights out) and rise times (lights on) are usually entered into the computer record from daily patient sleep logs or by patient-activated event markers. Proprietary software is then used to calculate periods of sleep based on the absence of detectable movement, along with movement-related periods of wake. In addition to providing graphic depiction of the activity pattern, device-specific software may analyze and report a variety of sleep parameters including sleep onset, sleep offset, sleep latency, total sleep duration, and wake after sleep onset. Numerous actigraphy devices have received U.S. Food and Drug Administration (FDA) marketing clearance through the 510(k) process.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

For applicable clinical criteria, see the following eviCore clinical guideline:


Denial Statements

No additional statements.


Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.


CPT® codes copyright American Medical Association® 2022. All rights reserved.

CDT codes copyright American Dental Association® 2022. All rights reserved.