Take Action

The AASM encourages members to participate in ongoing advocacy efforts, as much as possible, to add the voices of sleep facilities and providers.  Review the current list of template letters, created for communication with payers and other stakeholders, as appropriate.

Join the ‘Act on Actigraphy’ payer reimbursement campaign

The American Academy of Sleep Medicine has launched the “Act on Actigraphy” campaign highlighting the importance of actigraphy testing for sleep disorders and urging payers to reimburse health care professionals for this evidence-based medical service. Many payers still list actigraphy as “experimental” or do not reimburse for the service, presenting a significant access-to-care barrier for patients who would benefit from this sleep assessment. The AASM is reaching out to private and public payers, including the Centers for Medicare & Medicaid Services (CMS), to advocate for policy revisions allowing reimbursement for actigraphy as a standalone service. We ask that members take action and join in this payer advocacy campaign by downloading a template letter, urging payors to update policies to include reimbursement for actigraphy, as supported in the medical literature.

Blue Shield of California PAP Therapy Reimbursement Policy

Blue Shield of California has continued to deny reimbursement for positive airway pressure (PAP) therapy, when a device with only one respiratory monitoring belt is used in performing the patient’s diagnostic sleep study, despite ongoing AASM advocacy. Both the AASM clinical practice guidelines and the AASM Manual for the Scoring of Sleep and Associated Events support the use of devices with one respiratory monitoring belt. Click here to download and personalize a letter to request a policy update, consistent with AASM guidelines and the Scoring Manual, which can be sent to Medpolicy@blueshieldca.com.

Align with the AASM Recommended Hypopnea Scoring Criteria

While many payers have adopted the recommended AASM scoring criteria for hypopneas (≥3% oxygen desaturation and/or arousal), the AASM is aware of several private payers, that still require that AHI be calculated using ≥4% oxygen desaturation for hypopneas in order to be reimbursed for treatments for sleep apnea. Click here to download and personalize a template letter to request that private payers consider updating the AHI definition to the one currently recommended by the AASM. As AASM continues to advocate for policies to be updated, members that treat patients whose payers require the ≥4% desaturation for hypopneas (e.g., Medicare) are encouraged to score using both criteria.

Coverage of Appropriate Treatment for Insomnia

Many private payers have established medical policies and coverage guidelines for the treatment of insomnia. However, many of these policies were developed prior to the publication of the Behavioral and Psychological Treatments for Chronic Insomnia Disorder in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline, and are, therefore, not closely aligned with the guideline recommendations. Click here to urge private payers to review current insomnia treatment policies and make any necessary modifications to align their policies with the recently published AASM guideline, to support the practice of evidence-based medicine in adult patients with insomnia.

Appropriate coding for Treatment-Emergent Central Sleep Apnea

Electronic health record (EHR) vendors and payers are requiring an incorrect diagnosis code, G47.31, Primary Central Sleep Apnea, for Treatment-Emergent Central Sleep Apnea. Per the 3rd edition of the AASM International Classification of Sleep Disorders (ICSD-3), the appropriate diagnosis code is G47.39, Other sleep apnea. The use of this code is problematic for two reasons: First, sleep medicine physicians are compelled to choose a diagnostic code that is inconsistent for a specific diagnosis, to get the service documented and reimbursed.  Secondly, EHR system requirements are set based on the preferences for each facility/practice.  Click here to download and personalize the attached template letter to request the code be updated by your EHR vendor and/or payers.

Appeal Rejections Associated with Concomitant Narcolepsy Medications

Several payers have implemented prior authorization and medical policies that will not reimburse concomitant medications for narcolepsy treatment. Excessive daytime sleepiness (EDS) is a hallmark symptom of narcolepsy, and while existing pharmacologic interventions are sometimes effective in reducing EDS for many patients, clinicians must monitor ongoing treatments and use clinical judgment to determine whether patients may benefit from adjustments to the pharmacologic regimen, including the use of multiple medications to manage EDS. Click here to download and personalize a template appeal letter, requesting that payers modify policies or consider covering concomitant narcolepsy medications as an extra-contractual benefit.