Two large private payers, Aetna and Cigna, plan to implement downcoding policies beginning Oct. 1, 2025. The Aetna and Cigna policies will rely on automatic downcoding of evaluation and management (E/M) services without reviewing clinical documentation.
Downcoded claims may lead to appeals, delaying access to testing such as polysomnography, home sleep apnea testing and actigraphy, as well as treatment. This could worsen comorbidities and increase safety risks. Automatic downcoding also adds paperwork, diverting resources from direct patient care.
Sleep physicians routinely integrate complex data — including medical history, comorbidities and test results — during a single visit, and downcoding minimizes this effort. Persistent underpayment threatens to the viability of sleep practices and long-term patient access to specialized sleep care. Implementation of these policies will further exacerbate the problem.
AASM action plan
- AASM has sent letters to Aetna and Cigna explaining the issue and urging the payers to review clinical documentation instead of using downcoding algorithms.
- Members may download and personalize a template letter to send to each payer, encouraging reversal of the policies.
- AASM staff continues to reach out to schedule meetings with Aetna and Cigna representatives in advance of the implementation date.
Please contact coding@aasm.org with any questions regarding these downcoding policies or other coding and reimbursement issues.
