Payer Policy Scorecards

Payer policy scorecards were created to evaluate how effective payer policies are at establishing appropriate coverage for diagnostic sleep testing services. The intent of the scorecards is to encourage insurers to adopt evidence-based policies that support patient safety and delivery of high-quality care.

The following scorecards for several major payers are based on the careful review of their policies by the AASM Payer Policy Review Committee, and were sent to each payer in advance for comment before posting online.

Diagnostic Testing for Obstructive Sleep Apnea

The AASM Payer Policy Review Committee based the Diagnostic Testing for Obstructive Sleep Apnea (OSA) scorecard on the AASM’s 2017 clinical practice guideline on diagnostic testing for OSA. The scorecard’s nine criteria correspond to the clinical practice recommendations contained in the guideline. The Committee also developed a Template Policy, intended to serve as an additional resource, which exemplifies a policy that is in alignment with the AASM guideline on Diagnostic Testing for adult OSA.

The Diagnostic Testing for OSA Payer Policy Scorecard was modified by the Payer Policy Review Committee, to further clarify scorecard criteria.  The current version of the scorecard is Version 2, finalized on October 9, 2021. All policies reviewed with this modified scorecard will be labeled Version 2: Updated 10.9.21, in the footer.

Click here to access an initial analysis of the initiative Addressing Gaps Between Payer Policies and AASM Clinical Practice Guidelines Using Scorecards, published in the May 2020 issue of the Journal of Clinical Sleep Medicine.

AASM members are encouraged to email payer policies related to diagnostic testing for OSA to coding@aasm.org.

Active Policies

Aetna

Obstructive Sleep Apnea in Adults

Effective 12/17/2020 – 88%
Effective 07/08/2020 – 88%
Effective 02/18/2020 – 88%
Effective 03/15/2019 – 88%
Effective 10/17/2018 – 88%
Effective 05/15/2017 – 83%

AIM Specialty Health

Sleep Disorder Management – Diagnostic and Treatment Management

Effective 08/16/2020 – 54%
Effective 02/09/2020 – 54%
Effective 03/09/2019 – 46%

Used by Premera Blue Cross, Blue Cross Blue Shield of Massachusetts, and Independence Blue

Arkansas Blue Cross and Blue Shield

Sleep Apnea, Testing

Effective 07/2022 – 67%
Effective 07/2021 – 67%

Blue Cross and Blue Shield of Alabama

Polysomnography for Respiratory Sleep Disorders Testing

Effective 06/2022 – 61%
Effective 06/2021 – 61%

Blue Cross Blue Shield Federal Employee Program

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 10/01/2020 – 85%
Effective 10/01/2019 – 85%
Effective 04/15/2017 – 56%

Blue Cross Blue Shield of Florida

Sleep Testing

Effective 08/15/2021 – 92%
Effective 09/15/2019 – 90%
Effective 10/15/2018 – 90%
Effective 12/15/2016 – 69%

Blue Cross Blue Shield of Illinois

Sleep Apnea and Treatment

Effective 06/1/2018 – 87%

BlueCross BlueShield Kansas

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 06/21/2021 – 76%
Effective 01/01/2020 – 74%

BlueCross BlueShield of Louisiana

Diagnosis of Obstructive Sleep Apnea Syndrome

Effective 08/2022 – 77%

Blue Cross Blue Shield of Michigan and Blue Care Network

Sleep Disorders, Diagnosis and Medical Management

Effective 01/01/2020 – 92%
Effective 07/01/2018 – 63%
Effective 08/01/2016 – 54%

Blue Cross & Blue Shield of Mississippi

Sleep Disorders

Effective 03/28/2022 – 70%

Blue Cross Blue Shield of Montana

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 01/01/2019 – 73%

Blue Cross Blue Shield of New Mexico

Diagnosis and Medical Management of OSA Syndrome

Effective 01/01/2019 – 66%

BlueCross BlueShield of North Carolina

Sleep Apnea: Diagnosis and Medical Management

Effective 08/01/2020 – 90%
Effective 08/01/2019 – 92%
Effective 01/01/2019 – 86%
Effective 08/01/2017 – 86%

Blue Cross Blue Shield of North Dakota

Diagnosis and Treatment of Obstructive Sleep Apnea in Adults

Effective 03/01/2021 – 84%

Blue Cross Blue Shield of Rhode Island

Diagnostic Testing for Sleep Related Breathing Disorders

Effective 02/04/2014 – 51%

BlueCross BlueShield of South Carolina

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 05/2022 – 84%

BlueCross BlueShield of Texas

Diagnosis of Obstructive Sleep Apnea Syndrome

Effective 04/01/2023 – 64%

BlueCross BlueShield of Vermont

Sleep Disorders Diagnosis and Treatment

Effective 04/01/2022 – 69%

Blue Cross Blue Shield of Wyoming

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 06/30/2018 – 81%
Effective 06/01/2017 – 81%

Blue Shield of California

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 09/01/2020 – 78%
Effective 03/01/2020 – 78%
Effective 03/01/2020 – 90%
Effective 10/01/2017 – 63%

Capital BlueCross

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 04/01/2021 – 80%
Effective 09/01/2020 – 79%
Effective 02/01/2020 – 78%

CareCentrix

Diagnosis and Treatment of Sleep Disordered Breathing in Adults and Children

Effective 07/20/2022 – 61%
Effective 07/19/2021 – 67%

CareFirst BlueCross BlueShield

Sleep Disorders

Effective 11/18/2019 – 80%
Effective 10/15/2018 – 80%
Effective 02/20/2018 – 76%

Carelon

Sleep Disorder Management

Effective 02/11/2023 – 58%

Cigna

Effective 03/15/2022 – 95%
Effective 06/15/2020 – 80%
Effective 06/15/2019 – 82%
Effective 11/15/2016 – 62%

ConnectiCare

Obstructive Sleep Apnea Diagnosis and Treatment

Effective 02/14/2020 – 58%

Emblem Health

Obstructive Sleep Apnea Diagnosis and Treatment

Effective 02/14/2020 – 47%

eviCore

Effective 02/14/2020 – 91%
Effective 02/15/2019 – 90%
Effective 05/17/2018 – 87%
Effective 06/05/2017 – 73%

Used by Blue Cross Blue Shield of Minnesota and Blue Cross Blue Shield of Arizona

Geisinger Health Plan

Polysomnography and Sleep Studies

Effective 03/2021 – 77%
Effective 03/2018 – 67%

Government Employees Health Association

Obstructive Sleep Apnea Sleep Testing

Effective 03/2022 – 85%

Hawaii Medical Service Association

Polysomnography and Home Sleep Apnea Testing

Effective 12/17/2021 – 98%

Highmark Blue Cross Blue Shield Delaware

Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

Effective 1/1/2022 – 82%

Highmark Blue Cross Blue Shield of Pennsylvania

Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

Effective 1/1/2022 – 67%
Effective 12/16/2019 – 57%
Effective 07/31/2017 – 51%

Highmark Blue Cross Blue Shield West Virginia

Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

Effective 08/22/2022 – 75%

Horizon Blue Cross Blue Shield of New Jersey

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 07/14/2020 – 85%
Effective 12/10/2019 – 87%
Effective 05/01/2019 – 90%

Humana

Sleep Studies, Adult

Effective 08/07/2020 – 62%
Effective 06/25/2019 – 71%
Effective 05/25/2017 – 72%

Medica

Sleep Studies for Initial Diagnosis of Obstructive Sleep Apnea

Effective 07/18/2022 – 69%
Effective 12/18/2019 – 69%

National Imaging Associates, Inc.

Nocturnal Polysomnography & Home Sleep Test (2 policies)

Used by Harvard Pilgrim

Effective 01/01/2020 – 88%

Northeastern New York – Protocol

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 02/01/2022 – 86%

Priority Health

Obstructive Sleep Apnea Including UPPP and LAUP

Effective 08/20/2020 – 56%
Effective 05/27/2020 – 54%
Effective 07/01/2019 – 54%
Effective 02/01/2017 – 53%

QualChoice

Obstructive Sleep Apnea

Effective 11/30/2020 – 44%

UHC Oxford

Attended Polysomnography for Evaluation of Sleep Disorders

Effective 09/01/2020 – 69%

United HealthCare

Attended Polysomnography for Evaluation of Sleep Disorders

Effective 04/01/2020 – 63%
Effective 12/01/2017 – 63%
Effective 08/01/2017 – 40%

Retired Policies

Blue Cross Blue Shield of Arizona

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

* Retired – defer to eviCore

Effective 08/01/2017 – 71%

Blue Cross Blue Shield of Massachusetts*

Polysomnography and Home Sleep Testing

* Retired – defer to AIM Specialty Health

Effective 07/14/2014 – 43%

Blue Cross and Blue Shield of Minnesota*

Sleep Disorder Testing in Adults

* Retired – defer to eviCore

Effective 07/03/2017 – 59%

Excellus Blue Cross Blue Shield

Sleep Studies

Effective 10/20/2016 – 62%

Harvard Pilgrim*

Effective 12/03/2018 – 79%
Effective 09/01/2017 – 79%

* Retired – defer to National Imaging Associates, Inc.

Independence Blue

Sleep Disorder Testing and Positive Airway Pressure Therapy

* Retired – defer to AIM Specialty Health

Effective 10/14/2016 – 40%

Premera Blue Cross

Polysomnography and Home Sleep Study for Diagnosis of Obstructive Sleep Apnea

* Retired – defer to AIM Specialty Health

Effective 03/01/2017 – 76%

Note: The Payer Policy Scorecard initiative ended in June 2023, with a total of 51 policies scored by the AASM Payer Policy Review Committee. The final scores are included in the tables below. Visit the AASM Payer Advocacy page to learn about other AASM payer advocacy efforts.

Table 1. Total number of diagnostic testing policies reviewed and their final scores

Table 2. Improvement in scores for all revised policies after re-scoring