Payer Advocacy
The AASM understands our members’ concerns regarding private payer policies not aligning with the AASM practice standards. In light of the paradigm shift from in-center polysomnography and titration to HSAT and APAP, the AASM has been reaching out to private payers to ensure that the board-certified sleep medicine physician (BCSMP) is involved in the testing and management of patients. The AASM firmly believes that patients managed by the BCSMP receive high-quality care.
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.
- Letter to Medica (8/9/2019).
- Letter to QualChoice (8/13/2018).
- Letter to Cigna (1/18/2017)
- Letter to Horizon Blue (6/28/2016)
- Letter to BCBS Nebraska (7/2016)
- Letter to Anthem (10/5/2016)
- Letter to CAHABA (9/22/2016)
- Response letter CAHABA (11/16/2016)
- Letter to BCBS Alabama (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 |
|---|---|---|
Blue Cross Blue Shield
|
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 |
|---|---|---|
| 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 |
|---|---|---|
| Highmark Blue Cross Blue Shield | 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 |
|---|---|---|
| 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.