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.

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 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

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

BlueCross BlueShield Kansas

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 01/01/2020 – 74%

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 Montana

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 01/01/2019 – 73%

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 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 06/01/2020 – 78%
Effective 03/01/2020 – 90%
Effective 10/01/2017 – 63%

Capital BlueCross

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective 09/01/2020 – 79%
Effective 02/01/2020 – 78%

CareFirst BlueCross BlueShield

Sleep Disorders

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

Cigna

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%

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

Highmark Blue Cross Blue Shield of Pennsylvania

Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

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

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 06/25/2019 – 71%
Effective 05/25/2017 – 72%

National Imaging Associates, Inc.

Nocturnal Polysomnography & Home Sleep Test (2 policies)

Used by Harvard Pilgrim

Effective 01/01/2020 – 88%

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%

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%