Payer Advocacy
The AASM understands our members’ concerns regarding payer policies not aligning with AASM practice standards. The AASM firmly believes that patients should receive high quality, evidence-based care by appropriately trained and licensed healthcare professionals
The AASM is in touch with payers on a regular basis commenting on and requesting changes to policies so that these policies align with our recommended standards for patient-centered care. The following letters are some examples of how the AASM has worked with various payers to provide guidance on policy making.
- DME MACs – Philips PAP Recall (6/22/2021)
- CMS – Prior Authorization Proposed Rule Comments (1/4/2021)
- CGS Administrators, LLC – Inclusion of Snoring Diagnosis Code (5/12/2020)
- CMS – Coverage Criteria for Positional OSA Treatment (6/5/2020)
- US Department of Health and Human Services – Office Visit Payment Policy and Budget Neutrality (7/1/2020)
- DME MACs – Standard Written Orders (9/3/2020)
- Response letter from DME MACs (9/9/2020)
- CMS – 2021 Physician Fee Schedule and Quality Payment Program Proposed Rule Comments
(10/5/2020) - CAHABA – Concerns with Updated LCD (9/22/2016)
- Response letter from CAHABA (11/16/2016)
- Medica – PSG for PLMD and Parasomnias in Pediatric Patients (8/9/2019)
- QualChoice – Allowing for AASM accreditation (8/13/2018)
- Cigna – Daytime Sleepiness Requirement for Sleep Studies (1/18/2017)
- Horizon Blue – NovaSom as sole HSAT provider (6/28/2016)
- BCBS Nebraska – Incorrect society citation (7/2016)
- Anthem – Policy inconsistencies with AASM guidelines and correct coding (10/5/2016)
- BCBS Alabama – Expanding acceptable Board certifications (11/10/2016)
Payer Alignment with AASM Recommended Hypopnea Scoring Criteria
AASM’s position statement Polysomnography for Obstructive Sleep Apnea Should Include Arousal-Based Scoring: An American Academy of Sleep Medicine Position Statement, was published in the July 2018 issue of the Journal of Clinical Sleep Medicine. This position statement emphasizes the position of the AASM that the RECOMMENDED AASM Scoring Manual scoring criteria for hypopneas, which includes diminished airflow accompanied by either an arousal or ≥ 3% oxygen desaturation, in adults, be used to calculate the apnea hypopnea index (AHI); the sleep study metric used to measure the severity of sleep apnea. For a more detailed explanation, please click here. For reference, the table below lists which private payer policies align with AASM’s RECOMMENDED hypopnea scoring criteria:
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Aetna | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
Anthem Blue Cross Blue Shield
|
X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
|
X | |
|
X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Blue Cross Blue Shield Minnesota | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Blue Cross Blue Shield Massachusetts | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Blue Shield of California | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Capital Blue Cross | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| CareCentrix | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Cigna | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Connecticare | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Government Employees Health Association, Inc. | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Hawaii Medical Service Association | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Highmark Blue Cross Blue Shield | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Horizon Blue Cross Blue Shield of New Jersey | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| Medica | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| National Imaging Associates Magellan | X | X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
|
X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
|
X |
| Private Payer | ≥ 3% O2 Desaturation or Arousal (RECOMMENDED) |
4% O2 Desaturation |
|---|---|---|
| United Healthcare | X |
Please note that this is not a complete list of private payers, but will be updated on a monthly basis, as policies are reviewed. AASM members may send policies to coding@aasm.org for review.