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Changes to sleep study precertification requirements now in effect 

August 29, 2013    

Effective for dates of service on or after September 1, 2013, precertification is required for commercial members for sleep studies and continuous positive airway pressure (CPAP) titration in the facility setting (i.e., free standing sleep study center or hospital sleep study lab). 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 HealthSM (AIM), an independent company. AIM uses their Sleep Disorder Management Diagnostic & Treatment Guidelines, adopted by IBC and available on their website at www.aimspecialtyhealth.com, to guide the utilization of these services for our members. The guidelines involve integration of medical information from multiple sources to support the use of high-quality advanced 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 medical practice. It takes into consideration recommendations from:

  • American Academy of Sleep Medicine (AASM)
  • American Thoracic Society (ATS)
  • Agency for Healthcare Research and Quality (AHRQ)
  • Centers for Medicare & Medicaid Services (CMS)
IBC covers sleep studies and CPAP titration conducted in the home and facility setting based on the medical necessity criteria outlined in our Medical Policy #07.03.05o: Sleep Disorder Testing. Precertification is not required for sleep studies that are conducted in the home setting. CPAP titration in the home setting continues to require precertification through IBC based on the standard rules for rental of durable medical equipment.

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 cost-effective and safe for the member;
  • the level of care required by the member based on his or her medical history and current health status;
  • current standards in medical practice.
Member cost-sharing (deductible, coinsurance, and/or copayments) applies in accordance with the terms of the member’s benefit contract.

Obtaining precertification for sleep studies in the facility setting

Providers who request coverage for administration of a sleep study in a facility setting are required to provide details about the member's medical history to support the request.

All precertification requests for sleep studies and CPAP titration in a facility setting should be submitted through the AIM ProviderPortalSM, which can be accessed through the NaviNet® web portal by selecting Authorizations from the Plan Transactions menu, then AIM.

It is very important that providers use NaviNet to verify member-specific requirements or refer to the most current precertification requirement lists on our website. 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 changes to place of service options for sleep studies, please call Customer Service at 1-800-ASK-BLUE.

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