Important Change:
The Sleep Study Authorization program implementation date , previously scheduled for April 1, 2015 and earlier, has been changed to May 1, 2015.Please disregard all previous communications indicating earlier implementation dates.
Effective May1, 2015, Florida Blue and Florida Blue HMO (Health Options, Inc.)will implement the mandatory preservice review/prior authorization program for sleep and titration studies. The Sleep Study Authorization program applies to the following networks:
NetworkBlue (BlueOptionsSM), Health Options, Inc. (BlueCare®HMO) and Blue Select.
Florida Blue and Florida Blue HMO (Health Options, Inc.) have contracted with Sleep Management Solutions to manage the Sleep Study Authorization Program. The program is designed to maximize patient care in the most appropriate and affordable manner based on clinically accepted standards.
Providers Participating in the Sleep Study Authorization Program
Effective May1, 2015, providers who are subject to the Sleep Study Authorization Program must submit all sleep study procedures (as set forth on Appendix A) to Sleep Management Solutions for preservice review/prior authorization. Failure to seek a preservice review/authorization will result in a denial of the claim and the provider will not be entitled to compensation from Florida Blue or Florida Blue HMO or from the member for any such services rendered. The authorization requirement is applicable to all Florida Blue and Florida Blue HMO (Health Options, Inc.) products in which contracted providers participate
. This program will not apply to members who are covered through self-insured administrative services only (ASO) plans nor will it apply to any members of other Blue
Plans who may access the above networks through BlueCard®.
How to Obtain Prior Authorization through Sleep Management Solutions
• Access the Sleep Management Solutions website at www.sleepsms.com.
• You may also access the Sleep Management Solutions website through a link on Availity®1at availity.com ; select Payer Resources and then Florida Blue.
Important:
• Effective May 1, 2015, you must refer to the Prior Authorization Program section of the Florida Blue Manual for Physicians and Providers for a list of sleep study procedures that require prior authorization. You can access the provider manual at providermanual.bcbsfl.com on our home page at www.floridablue.com/authorization.
• Appendix A on the following page also provides a list procedures included in the program.
If you have any questions or require any additional information about this information, please call the Provider Contact Center at (800) 727-2227
BENEFIT CONSIDERATIONS - oxford insurance
Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable.
Indications for Coverage
* Medical or surgical treatment of snoring is covered only if that treatment is determined to be part of a proven treatment for documented Obstructive Sleep Apnea (OSA). Refer to the applicable medical policy to determine if the treatment proposed is proven for OSA.
* Oral appliances for snoring with a diagnosis of OSA are addressed in the Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements policy. Coverage Limitations and Exclusions
* Medical treatment for primary snoring, without a diagnosis of OSA, that includes Positive Airway Pressure (PAP) equipment or oral appliances identified via a clinical review, is not a Covered Health Service.
* Surgical treatments for primary snoring, without a diagnosis of OSA, are not a Covered Health Service. Examples include, but are not limited to:
o Uvulopalatopharyngoplasty (UPPP)
o Laser-Assisted Uvulopalatoplasty (LAUP)
o Somnoplasty
o Submucosal radiofrequency tissue volume reduction
Essential Health Benefits for Individual and Small Group
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.
COVERAGE RATIONALE
Home Sleep Apnea Testing (HSAT), using a portable monitor, is Medically Necessary for evaluating adults with suspected OSA.
Where HSAT is indicated, an Autotitrating Positive Airway Pressure (APAP) device is an option to determine a fixed PAP pressure.
Restless Legs Syndrome (RLS)/Willis-Ekbom Disease: RLS is a sensorimotor disorder characterized by a complaint of a strong, irresistible urge to move the limbs. This urge to move is often, but not always, accompanied by other uncomfortable sensations felt deep inside the limbs or by a feeling that is difficult or impossible to describe. Although the legs are most prominently affected, these sensations may occur in the arms as well.
Appendix A
Sleep Study Procedures (Procedure list is subject to change.)
95782 - Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
95783 - Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
95800 - Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis(e.g., by air flow or peripheral arterial tone), and sleep time
95801 - Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
95806 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist
95807 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
95808 - Polysomnography; any age, sleep staging with 1 –3 additional parameters of sleep, attended by a technologist
95810 - Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
95811 - Polysomnography; age 6 or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by technologist
G0398 - Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
G0399 - Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen
G0400 - Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
Note: The list above is not all-inclusive.
The Americam Medical Association (AMA) added new CPT codes 95782 and 95783and amended 95808, 95810 and 95811 effective with date of service January 1, 2013
Code(s) Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer documented in the policy.
If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code.
CPT Code(s)
95805
95806
95807
95808
95810
95811
95782
95783
Unlisted Procedure or Service
CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service.
HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS National Level II codes, Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service.
D. Modifiers
Provider(s) shall follow applicable modifier guidelines.
E. Billing Units The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).
1. Polysomnography and sleep studies may be billed as a complete procedure or as professional and technical components.
a. Polysomnography and sleep studies are limited to one procedure per date of service by the same or different provider.
b. The technical or the professional component cannot be billed by the same or different provider on the same date of service as the complete procedure is billed.
c. The complete procedure is viewed as an episode of care that may start on one day and conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that should be billed. The complete procedure should not be billed with two dates of services.
d. If components are billed, the technical and the professional components should be billed with the date the service was rendered as the date of service.
2. Separate reimbursement is not allowed for the following procedures on the same date of service by the same or different provider:
a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with sleep studies and polysomnography (CPT codes 95805 through 95811).
b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760 and 94761) with sleep studies and polysomnography (CPT codes 95805 through 95811).
c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour, continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95805 through 95806) (age six and under).
d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT code 94660) with polysomnography (CPT code 95811).
e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT codes 95808 through 95811).
f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes 95808 through 95811).
The Sleep Study Authorization program implementation date , previously scheduled for April 1, 2015 and earlier, has been changed to May 1, 2015.Please disregard all previous communications indicating earlier implementation dates.
Effective May1, 2015, Florida Blue and Florida Blue HMO (Health Options, Inc.)will implement the mandatory preservice review/prior authorization program for sleep and titration studies. The Sleep Study Authorization program applies to the following networks:
NetworkBlue (BlueOptionsSM), Health Options, Inc. (BlueCare®HMO) and Blue Select.
Florida Blue and Florida Blue HMO (Health Options, Inc.) have contracted with Sleep Management Solutions to manage the Sleep Study Authorization Program. The program is designed to maximize patient care in the most appropriate and affordable manner based on clinically accepted standards.
Providers Participating in the Sleep Study Authorization Program
Effective May1, 2015, providers who are subject to the Sleep Study Authorization Program must submit all sleep study procedures (as set forth on Appendix A) to Sleep Management Solutions for preservice review/prior authorization. Failure to seek a preservice review/authorization will result in a denial of the claim and the provider will not be entitled to compensation from Florida Blue or Florida Blue HMO or from the member for any such services rendered. The authorization requirement is applicable to all Florida Blue and Florida Blue HMO (Health Options, Inc.) products in which contracted providers participate
. This program will not apply to members who are covered through self-insured administrative services only (ASO) plans nor will it apply to any members of other Blue
Plans who may access the above networks through BlueCard®.
How to Obtain Prior Authorization through Sleep Management Solutions
• Access the Sleep Management Solutions website at www.sleepsms.com.
• You may also access the Sleep Management Solutions website through a link on Availity®1at availity.com ; select Payer Resources and then Florida Blue.
Important:
• Effective May 1, 2015, you must refer to the Prior Authorization Program section of the Florida Blue Manual for Physicians and Providers for a list of sleep study procedures that require prior authorization. You can access the provider manual at providermanual.bcbsfl.com on our home page at www.floridablue.com/authorization.
• Appendix A on the following page also provides a list procedures included in the program.
If you have any questions or require any additional information about this information, please call the Provider Contact Center at (800) 727-2227
BENEFIT CONSIDERATIONS - oxford insurance
Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable.
Indications for Coverage
* Medical or surgical treatment of snoring is covered only if that treatment is determined to be part of a proven treatment for documented Obstructive Sleep Apnea (OSA). Refer to the applicable medical policy to determine if the treatment proposed is proven for OSA.
* Oral appliances for snoring with a diagnosis of OSA are addressed in the Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements policy. Coverage Limitations and Exclusions
* Medical treatment for primary snoring, without a diagnosis of OSA, that includes Positive Airway Pressure (PAP) equipment or oral appliances identified via a clinical review, is not a Covered Health Service.
* Surgical treatments for primary snoring, without a diagnosis of OSA, are not a Covered Health Service. Examples include, but are not limited to:
o Uvulopalatopharyngoplasty (UPPP)
o Laser-Assisted Uvulopalatoplasty (LAUP)
o Somnoplasty
o Submucosal radiofrequency tissue volume reduction
Essential Health Benefits for Individual and Small Group
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.
COVERAGE RATIONALE
Home Sleep Apnea Testing (HSAT), using a portable monitor, is Medically Necessary for evaluating adults with suspected OSA.
Where HSAT is indicated, an Autotitrating Positive Airway Pressure (APAP) device is an option to determine a fixed PAP pressure.
Restless Legs Syndrome (RLS)/Willis-Ekbom Disease: RLS is a sensorimotor disorder characterized by a complaint of a strong, irresistible urge to move the limbs. This urge to move is often, but not always, accompanied by other uncomfortable sensations felt deep inside the limbs or by a feeling that is difficult or impossible to describe. Although the legs are most prominently affected, these sensations may occur in the arms as well.
Appendix A
Sleep Study Procedures (Procedure list is subject to change.)
95782 - Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
95783 - Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
95800 - Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis(e.g., by air flow or peripheral arterial tone), and sleep time
95801 - Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
95806 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist
95807 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
95808 - Polysomnography; any age, sleep staging with 1 –3 additional parameters of sleep, attended by a technologist
95810 - Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
95811 - Polysomnography; age 6 or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by technologist
G0398 - Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
G0399 - Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen
G0400 - Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
Note: The list above is not all-inclusive.
The Americam Medical Association (AMA) added new CPT codes 95782 and 95783and amended 95808, 95810 and 95811 effective with date of service January 1, 2013
Code(s) Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer documented in the policy.
If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code.
CPT Code(s)
95805
95806
95807
95808
95810
95811
95782
95783
Unlisted Procedure or Service
CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service.
HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS National Level II codes, Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service.
D. Modifiers
Provider(s) shall follow applicable modifier guidelines.
E. Billing Units The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).
1. Polysomnography and sleep studies may be billed as a complete procedure or as professional and technical components.
a. Polysomnography and sleep studies are limited to one procedure per date of service by the same or different provider.
b. The technical or the professional component cannot be billed by the same or different provider on the same date of service as the complete procedure is billed.
c. The complete procedure is viewed as an episode of care that may start on one day and conclude on the next day. When billing for the complete procedure, the date that the procedure began is the date of service that should be billed. The complete procedure should not be billed with two dates of services.
d. If components are billed, the technical and the professional components should be billed with the date the service was rendered as the date of service.
2. Separate reimbursement is not allowed for the following procedures on the same date of service by the same or different provider:
a. Electrocardiographic monitoring for 24 hours (CPT codes 93224 through 93272) with sleep studies and polysomnography (CPT codes 95805 through 95811).
b. Non-invasive ear or pulse oximetry single or multiple determinations (CPT codes 94760 and 94761) with sleep studies and polysomnography (CPT codes 95805 through 95811).
c. Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour, continuous recording, infant, (CPT code 94772) with sleep studies (CPT codes 95805 through 95806) (age six and under).
d. Continuous positive airway pressure ventilation, CPAP, initiation and management, (CPT code 94660) with polysomnography (CPT code 95811).
e. Electroencephalogram (CPT codes 95812 through 95827) with polysomnography (CPT codes 95808 through 95811).
f. Facial nerve function studies (CPT code 92516) with polysomnography (CPT codes 95808 through 95811).
References:
[3] Comprehending Polysomnography Codes 95782–95783 – MedLearn Publishing. Retrieved from
http://www.cms1500claimbilling.com/2015/11/sleep-study-authorization-program.html