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New preauthorization requirements for diagnosis and treatment of obstructive sleep apnea

07/30/2018

Our new medical policy for diagnosis and treatment of obstructive sleep apnea (OSA) requires preauthorization for these services on or after Sept. 1, 2018:

  • Sleep studies
  • OSA treatment, including, but not limited to dental devices, CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) machines 

There are no changes to our existing coverage of supplies, such as masks and tubing, used with the equipment above. You will not need preauthorization for these supplies.

The new policy applies to all ConnectiCare commercial and Medicare Advantage plans. It will not apply to treatment before Sept. 1.

The policy will soon be published on the medical criteria page of our provider website. Check back for details.

You can start faxing preauthorization requests to 860-674-5893 (commercial) or 866-706-6929 (Medicare), or call 800-923-2882 (commercial) or 800-508-6157 (Medicare) after Aug. 1 for dates of service on or after Sept 1. We will review requests for medical necessity and location of service. Make sure to include all supporting clinical patient information.

Also starting Sept. 1, we will implement a new medical necessity and level of care review for all attended (in-lab sleep facility) polysomnography for patients age 19 or older who have high pre-test probability of OSA. These requests will need medical director review and must meet the criteria and note other atypical or complicating symptoms that could impair the test’s accuracy, such as:

  • Severe heart failure (EF ≤ 15 or NYHA Class IV)
  • Chronic obstructive pulmonary disease (COPD) and restrictive pulmonary disorders: (FEV1 <30 or PCO2 >45)
  • Atrial fibrillation
  • Significant tachyarrhythmia or bradyarrhythmia cases where unattended monitoring is technically inadequate or fails to establish the diagnosis of OSA in patients with high pre-test probability.