Prior Authorization
Private Payers
Prior authorization is a cost control practice utilized by payers to request preapproval of specific medical services, prescriptions, or supplies creating additional administrative burden for providers. This practice impacts providers and beneficiaries of both public and private payers and can lead to delayed care for patients and additional administrative burden for providers.
The AASM continues to advocate for changes to prior authorization requirements, including supporting the American Medical Association’s efforts to advocate for changes to prior authorization requirements and policies, by requesting that payers align with the Prior Authorization and Utilization Management Principles, and also make the following changes:
- Implement long-term authorizations for chronic and terminal conditions to eliminate the need for repeat reviews
- When a prior authorization decision is reached for a chronic or terminal condition by one payer, allowing that decision to be shared and remain valid if the patient changes payers.
Review the AASM’s growing efforts to advocate for Prior Authorization reform here and review the AASM response to a recent Proposed Rule on Prior Authorization by clicking here.
The AASM has also reviewed several policies of major payers to identify which diagnostic sleep studies require prior authorization.*
| Private Payer Prior Authorization Requirements | |||||
|---|---|---|---|---|---|
| Home Sleep Apnea Tests (HSAT) | Polysomnography (PSG) | Actigraphy | Multiple Sleep Latency Test (MSLT) | Maintenance of Wakefulness Test (MWT) | |
| Aetna | N | Y | N | Y | Y |
| AIM Specialty Health | Y | Y | N | Y | Y |
| Anthem | Y | Y | Y | Y | Y |
| Centene | Y | Y | Y | Y | Y |
| Cigna | N | Y | N | Y | Y |
| CVS Health** | N | N | N | N | N |
| HCSC | Y | Y | Y | Y | Y |
| Humana | N | Y | N | Y | Y |
| Molina Health | N | Y | Y | Y | Y |
| United Healthcare | N | Y | N | Y | Y |
| United Healthcare Oxford | N | Y | Y | Y | Y |
* This information was last revised in May 2022.
** Prior authorization required for repeat studies.
Centers for Medicare & Medicaid Services (CMS)
CMS is actively working to update prior authorization policies and the list of applicable services, prescriptions, and supplies.
As of April 13, 2022, CMS will add 31 additional HCPCS codes to their Master List that could potentially be subject to face-to-face encounters and written orders prior to delivery and/or prior authorization requirements, including face masks for CPAP devices. Once updated, there will be 439 items on the Master List. The purpose of these updates is to ensure applicable coverage, payment, and coding rules are met before items are delivered, and to protect the Medicare Trust Fund from improper payments.
CMS selects items for inclusion on the Master List, based on three criteria, including:
- Per statute
- The item appears to be a source of potential fraud or unnecessary utilization based on an OIG report, GAO report, or Certified Error Rate Testing (CERT) Improper Payment Data report (and the item also meets the applicable cost threshold).
- The item has been subject to abnormal billing patterns.
From time to time, CMS also considers factors such as geographic location, item utilization or cost, system capabilities, emerging trends, vulnerabilities identified in official agency reports, or other analysis, to select items from the Master List for inclusion on one or both required lists.
View CMS prior authorization resources via the links below.
Prior Authorization and Pre-Claim Review Initiatives
Review the AASM’s growing efforts to advocate for Prior Authorization reform here and review the AASM response to a recent Proposed Rule on Prior Authorization by clicking here.
General questions about prior authorization can be sent to coding@aasm.org. For questions about requirements for specific payers, please contact the payer directly.