Guideline 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, were approved by the AASM Board of Directors, and 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.
- Obstructive Sleep Apnea in Adults (policy effective 5/15/2017)
- Obstructive Sleep Apnea in Adults (revised policy effective 10/17/2018)
AIM Specialty Health
- Sleep Disorder Management Diagnostic & Treatment Guidelines (policy effective 5/15/2017)
Blue Care Network and Blue Cross and Blue Shield of Michigan
- Sleep Disorders, Diagnosis and Medical Management (policy effective 8/1/2016)
- Sleep Disorders, Diagnosis and Medical Management (revised policy effective 7/1/2018)
Blue Cross and Blue Shield of Florida
- Sleep Studies (policy effective 12/15/2016)
Blue Cross and Blue Shield of Minnesota
- Sleep Disorder Testing in Adults (policy effective 7/3/2017)
Blue Cross Blue Shield of North Carolina
- Sleep Apnea: Diagnosis and Medical Management (policy effective 8/2017)
Blue Cross Blue Shield Federal Employee Program
- Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome (policy effective 5/15/2017)
Blue Cross Blue Shield of Arizona
- Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome (policy effective 8/2017)
Blue Cross Blue Shield of Massachusetts
- Polysomnography and Home Sleep Testing (policy effective 7/14/2014)
Blue Cross Blue Shield of Wyoming
- Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome (policy effective 6/2017)
Blue Shield of California
- Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome (policy effective 10/1/2017)
CareFirst Blue Cross Blue Shield
- Sleep Disorders (policy effective 2/20/2018)
- OSA Diagnosis and Treatment Services (policy effective 9/1/2016)
- Sleep Apnea and Treatment, v6.0.2018 (policy effective 5/17/18)
- Sleep Apnea and Treatment Guidelines (policy effective 6/5/2017)
Excellus Blue Cross Blue Shield
- Sleep Studies (policy effective 10/20/2016)
- Sleep Study Attended (policy effective 9/2017)
Highmark Blue Cross Blue Shield Pennsylvania
- Diagnosis and Treatment of Obstructive Sleep Apnea in Adults (policy effective 1/1/2017)
- Sleep Studies, Adult (policy effective 5/25/17)
- Sleep Disorder Testing and Positive Airway Pressure Therapy (policy effective 10/14/2016)
Premera Blue Cross
- Polysomnography and Home Sleep Study for Obstructive Sleep Apnea (policy effective 3/1/2017)
- Obstructive Sleep Apnea (policy effective 2/1/2017)
- Attended Polysomnography for Evaluation of Sleep Disorders (policy effective 12/1/2017)
- Attended Polysomnography for Evaluation of Sleep Disorders (policy effective 8/1/2017)
AASM Communication with Private Payers
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 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)
Recently, insurance companies have started implementing utilization management programs for sleep testing. Utilization management is a tool/technique used to determine if a procedure or test is medically necessary. Usually, this technique is used for high-cost procedures and is intended to reduce unnecessary testing or procedures. In the case of sleep medicine, utilization management is used to determine when in-center testing is necessary and when a patient can be tested using HSAT.
Insurers often contract with outside companies to administer their utilization management program. These companies advertise reduced testing and procedure costs that result from implementing their utilization management programs. The utilization management company will work with the insurer to establish an authorization process for testing. These processes vary from insurer to insurer. Depending on the insurance policy and the utilization management company, sleep utilization management can be labor intensive for the provider. It can also limit the physician’s ability to make clinical decisions for his/her patients.
Recently, more and more private insurers have started requiring preauthorization prior to sleep testing. Preauthorization is the process of confirming with an insurer not only whether or not a test or treatment is a covered service but also whether or not it is considered medically necessary for a specific patient. As described above, insurance companies frequently use utilization management companies to review preauthorization documentation. For sleep, this documentation can include signs and symptoms of OSA as well as a list of co-morbid conditions which might result in the patient requiring in-center sleep testing.