969 Form

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Medical Policy Carelon (formerly AIM) Sleep Disorder Management
Policy Number: 969 BCBSA Reference Number: N/A NCD/LCD: N/A Effective Date: September 1, 2019 Related Policies
• Medicare Advantage: Carelon Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923 • Carelon Sleep Disorder Management CPT, HCPCS and Diagnoses Codes, #970
• Carelon Advanced Imaging/Radiology, #968
• Carelon Advanced Imaging/Radiology CPT and HCPCS, #900
• Carelon Advanced Imaging of the Heart, #972
• Carelon Advanced Imaging of the Heart CPT, HCPCS and Diagnoses Codes, #971

Overview:
Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management.

Policy and Coverage Criteria for Commercial Products: The Carelon Medical Benefits Management Clinical Guidelines include medical necessity criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral Appliances
Management of Obstructive Sleep Apnea (OSA) using Auto-Titrating Positive Airway Pressure (APAP) and Continuous Positive Airway Pressure (CPAP) Devices Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT)
Polysomnography and Home Sleep Testing

Requesting Prior Authorization Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS)

Commercial PPO and EPO
The requirements of BCBSMA Sleep Management Program may require prior authorization via AIM Specialty Health. These requirements are member-specific:

Please verify member eligibility and requirements through Online Services by logging onto Provider Central. Refer to our Quick Tip for an overview of pre-certification and prior authorization requirements.

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Ordering clinicians should request prior authorization from Carelon Medical Benefits Management or call 1-866-745-1783 (when applicable).

Prior authorization information for Medicare HMO Blue and Medicare PPO Blue is addressed in medical policy #923, Advanced Imaging/Radiology and Sleep Disorder Management for Medicare Advantage Products.

Indemnity Prior authorization is not required.

Sleep Disorder Management for Medicare Advantage Products Prior authorization through Carelon Medical Benefits Management is required for Medicare Advantage products.

The following sleep disorder management medical policies will be retired effective September 1, 2019.
These policies will no longer be available on the BCBSMA website as of this date. For medically necessary indications, see the Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder Diagnostic and Treatment.

Retired Medical Policies Policy Number Bi-Level Positive Airway Pressure (BPAP) Devices 527 Management of Obstructive Sleep Apnea (OSA) Oral Appliances
529 Management of Obstructive Sleep Apnea (OSA) using Auto-Titrating Positive Airway Pressure (APAP) and Continuous Positive Airway Pressure (CPAP) Devices 526 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT)
534 Polysomnography and Home Sleep Testing
525

Disclaimer:
Coverage is subject to applicable benefit contract. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Member’s medical records must document that services are medically necessary for the care provided. BCBS MA maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available upon request. Failure to produce the requested information may result in denial or retraction of payment.

References: Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder Diagnostic and Treatment