Beginning September 1, 2013, IBC will provide coverage for sleep studies as
follows:
Precertification will be required for facility-based sleep studies and
facility-based continuous positive airway pressure (CPAP) titration studies
based on the medical necessity criteria outlined in the upcoming Medical Policy
#07.03.05o: Sleep Disorder Testing.
Sleep studies that are conducted in the home setting will not require
precertification.
CPAP titration in the home setting will continue to require precertification
based on the applicable rules for rental of durable medical equipment (DME).
These changes are being made due to medical advances in home sleep study
testing.[
]1-5[]
Use the [
]Find a Doctor[] tool to find a list
of IBC-participating home-based sleep study providers and DME suppliers.
[
]Upcoming changes[
]
Effective for dates of service on or after September 1, 2013, precertification
for commercial HMO and PPO members for sleep studies and CPAP titration in the
facility setting (freestanding sleep study center or hospital sleep study lab)
will be required. This change will also be implemented for Medicare Advantage
HMO and PPO members effective January 1, 2014.
IBC has delegated the responsibility for precertification of sleep studies and
CPAP titration studies in the facility setting to AIM Specialty
Health[
]SM[] (AIM), an independent company. AIM will use their Sleep
Disorder Management Diagnostic & Treatment Guidelines, adopted by IBC and
available on the [
]AIM
website[] to determine the most appropriate settings for these services for
our members. The AIM guidelines involve integration of medical information from
multiple sources to support the use of high-quality sleep management services.
The process for criteria development is based on technology assessment and
peer-reviewed medical literature, including clinical outcomes research and
consensus opinion in current medical practice. It takes into consideration
recommendations from the American Academy of Sleep Medicine, American Thoracic
Society, Agency for Healthcare Research and Quality, and Centers for Medicare &
Medicaid Services.
Members should obtain sleep studies and CPAP titration in the setting that is
most appropriate for their condition, based on factors such as:
the setting that has been determined to be both safe and cost-effective for the
member;
the level of care required by the member during the sleep study, based on his
or her medical history and current health status;
current standards in medical practice.
Member cost-sharing (i.e., deductible, coinsurance, and/or copayment) applies
in accordance with the terms of the member's benefits contract.
[
]Advantages of home-based sleep studies[
]
Home sleep studies offer high value in a low-cost setting. Evidence shows that
home-based sleep studies in select patient populations are equivalent in
accuracy to facility-based sleep studies . and are more
cost-effective.[
]1-5[] Furthermore, many patients prefer the
convenience of receiving the sleep study monitoring in their home. Providers
should discuss this option with their patients, when appropriate.
Typically, only those patients with significant comorbidities or who are
suspected to have a sleep disorder other than obstructive sleep apnea (OSA)
require a higher level of care during the testing at an outpatient sleep study
facility or hospital. Most patients can safely undergo the sleep study and CPAP
titration in their home. When performed properly, at-home sleep studies using
an appropriate portable monitor can accurately diagnose most adult patients
with a high pretest probability of moderate-to-severe OSA.[
]1-5[]
[
]Obtaining precertification for sleep studies in a facility
setting[
]
Providers who request coverage for administration of a sleep study in a
facility setting will be required to submit details about the member?s medical
history to support the request, in accordance with the revised Medical Policy.
All precertification requests for sleep studies and CPAP titration in a
facility setting should be submitted through the AIM
ProviderPortal[
]SM[], which can be accessed through the
NaviNet[
]?[] web portal by selecting Authorizations from the Plan
Transactions menu, then AIM. Providers can also call [
]1-800-ASK-BLUE[].
Please note that you should continue to submit precertification requests for
CPAP titration in the home setting directly to IBC.
It is very important that providers use NaviNet to verify member-specific
requirements or refer to the most current [
]precertification requirement
lists[]. Failure to obtain precertification for any of the services that
require it may result in a reduction in payment or nonpayment for the services
not precertified.
If you have any questions about these upcoming changes to place-of-service
options for sleep studies, please call Customer Service at [
]1-800-ASK-BLUE[].
[
]References[
]
[
]
[]1[] Rosen CL, Auckley D, Benca R, et al. A multisite randomized
trial of portable sleep studies and positive airway pressure autotitration
versus laboratorybased polysomnography for the diagnosis and treatment of
obstructive sleep apnea: the HomePAP study. Sleep. 2012 Jun
1;35(6):757-67.[
]
[]2[] Masa JF, Corral J, Pereira R, et al. Effectiveness of home
respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea
syndrome. Thorax. 2011 Jul;66(7):567-73.[
]
[]3[] Domingo C, Vigil L. Effectiveness of unattended ambulatory
sleep studies for the diagnosis and treatment of OSAS. J Eval Clin Pract. 2011
Feb;17(1):26-31.[
]
[]4[] Deutsch PA, Simmons MS, Wallace JM. Cost-effectiveness of
split-night polysomnography and home studies in the evaluation of obstructive
sleep apnea syndrome. J Clin Sleep Med. 2006 Apr 15;2(2):145-53.[
]
[]5[] Collop N, Anderson M, Boehlecke B, et al. Clinical guidelines
for the use of unattended portable monitors in the diagnosis of obstructive
sleep apnea in adult patients. Journal of Clinical Sleep Medicine. 2007;3(7):
737-747.[
]
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