Beginning September 1, 2013, AmeriHealth 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 [
]Provider Finder[] tool to find a list of AmeriHealth-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 members effective January 1, 2014.AmeriHealth has delegated the responsibility for precertification of sleep studies and CPAP titration studies in the facility setting to AIM Specialty Health[
]SM[] (AIM). AIM will use their Sleep Disorder Management Diagnostic & Treatment Guidelines, adopted by AmeriHealth 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 [
]1-800-275-2583[] for Pennsylvania and Delaware members or [
]1-800-859-5288[] for AmeriHealth New Jersey members.Please note that you should continue to submit precertification requests for CPAP titration in the home setting directly to AmeriHealth.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 [
]1-800-275-2583[].[
]References[
][][
NaviNet® is a registered trademark of NaviNet, Inc.
]