Sleep Management Program (Testing and Treatment with Positive Airway Pressure)

Only providers who have signed a specific sleep testing agreement may provide sleep management services to BCN members.

Sleep study candidates include habitual snorers with daytime sleepiness or observed apnea (cessation of breathing lasting 10 seconds or more). Daytime sleepiness can be determined by using a common assessment tool available to health care providers, such as the Epworth Sleepiness Scale, Stanford Sleepiness Scale or the STOP-BANG model.

Home sleep studies allow for testing in the comfort of the member’s own bed and are particularly useful in rural areas where the nearest sleep center may be hours away. Blue Care Network's medical policy on the diagnosis and management of obstructive sleep apnea includes coverage for home sleep studies for members with symptoms of OSA without other comorbid conditions.

Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description:

  • Have a high pretest probability of moderate to severe obstructive sleep apnea
  • Have no exclusions or contraindications to having a sleep study in the home

Home sleep studies do not require clinical review but providers must submit a request for authorization to facilitate claims payment. Providers are not required to complete a questionnaire for these services in the e-referral system.

Hospitals billing for services related to home sleep studies must execute a specific sleep testing agreement and bill in accordance with BCN requirements. Claims are payable only if they are billed globally. Claims submitted on a UB-04 claim form are not payable.

Home sleep study providers can be identified using BCN’s online provider search at Search for “home sleep testing”. For more specific instructions, refer to the document Finding home sleep study providers.

Outpatient facility or clinic-based sleep studies are also covered by BCN for the following members:

  • Pediatric members (17 years of age or younger) with symptoms of obstructive sleep apnea
  • Adult members with symptoms of obstructive sleep apnea who completed a home sleep study that was nondiagnostic or who have exclusions or contraindications to having a sleep study in the home

Prior authorization is required for BCN members who are 18 years of age or older. This applies to commercial members — including those covered through self-funded groups — and BCN AdvantageSM members.

When a prior authorization request is submitted for a sleep study to be performed in an outpatient facility or clinic-based setting, the e-referral system prompts the submitter to complete a questionnaire to determine the appropriateness of the request. The questionnaire items are aligned with the Blue Cross/BCN medical policy titled Sleep Disorders, Diagnosis and Medical Management. You can review the preview questionnaire to familiarize yourself with the questions you'll see on the e-referral system questionnaire.

Your responses on the questionnaire help determine whether the clinical guidelines are met. In addition, the comments you enter and the documentation you attach in the e-referral Case Communication field assist with medical necessity decisions for cases that are not automatically approved.

In addition, all requests to authorize outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older will require the submission of evidence from the member’s medical record. This evidence must both confirm signs and symptoms of obstructive sleep apnea and indicate the specific condition the member has that would exclude or contraindicate a home sleep study. This applies to BCN commercial and BCN Advantage members. Any documentation from the member’s medical record that is required can be attached to the request within the e-referral system, in the Case Communication field.

Sleep study billing guidelines

For information on how to bill sleep study claims, refer to the article Guidelines for billing sleep studies, with updates on authorization requirements on page 42 of the July-August 2016 issue of BCN Provider News.

Positive airway pressure devices for the treatment of obstructive sleep apnea
BCN provides coverage for PAP devices for members who meet medical necessity criteria. The guidelines for initial coverage are found in the Blue Cross/BCN medical policy titled Sleep Disorders - Diagnosis and Medical Management.

Members who use PAP devices must show they’re complying with their treatment recommendations in order to use the devices for longer than 90 days. This applies to requests for clinical review BCN commercial and BCN Advantage members. For members meeting the initial coverage criteria for these devices, Northwood, Inc., BCN’s durable medical equipment benefit manager, will authorize use of the devices only for a three-month period.

Review the details of the new process for submitting compliance data, including the compliance responsibilities that must be carried out by the member, the member’s practitioner, Northwood and the DME supplier, in the November-December 2014 BCN Provider News issue, on pages 48 and 49.

For more information
Review the Blue Cross / BCN medical policy titled Sleep Disorders - Diagnosis and Medical Management.