Notification

Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (AmeriHealth)


Notification Issue Date: 11/11/2019

This version of the policy will become effective 02/09/2020. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 02/09/2020. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:

  • Added chronic narcotic use as a contraindication to APAP.
  • Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension.


Medical Policy Bulletin


Title:Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (AmeriHealth)

Policy #:07.03.05w



The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy


Refer to the following News Articles:

Respiratory Equipment and Related Supplies (updated June 11, 2020)

Waiver of certain requirements during COVID-19 outbreak related to Durable Medical Equipment (DME), prosthetics, orthotics, and supplies

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to AmeriHealth New Jersey and AmeriHealth Pennsylvania members. This policy does not apply to those members for whom AmeriHealth Administrators serves as the claims administrator.

The Company has delegated the responsibility for utilization management activities for the following sleep disorder testing and positive airway pressure therapy services and supplies to AIM Specialty Health® (AIM) with the exception of services performed in the emergency room or during an inpatient or observation unit stay.

For information on policies related to this topic, refer to the Cross References section in this policy.

Please refer to the References section of this policy for a link to the entire AIM Clinical Appropriateness Guidelines for Sleep Disorder Management, as well as all applicable procedure codes.

AIM utilizes their Clinical Appropriateness Guidelines for Sleep Disorder Management to determine the medical necessity for the following services:
  • Facility-based sleep disorder testing and positive airway pressure (PAP) titration
  • Home-based sleep disorder testing and PAP titration
  • Positive airway pressure therapy
  • Supplies related to PAP therapy


BILLING REQUIREMENTS

For those specific circumstances where less than six hours of monitoring and recording of PSG are utilized or warranted, specific documentation must be maintained in the medical record as to why a shortened study was "reasonable and necessary." Under these circumstances, the PSG would be billed with the 52 modifier to signify that a "reduced service" was performed and will be reimbursed accordingly.

The performance of multiple nights of home sleep testing is considered one study (1 unit of service) because it is performed as a single episode of testing. The date of service should be reported as the date the study is completed.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, sleep disorder testing and positive airway pressure therapy services and supplies are covered under the medical benefits of the Company’s products when medical necessity criteria for the services and supplies are met.

However, services that are identified as not medically necessary or experimental/ investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of single-level continuous positive airway pressure (CPAP), auto-adjusting positive airway pressure (APAP), and bi-level positive airway pressure (BPAP) for obstructive sleep apnea and/or respiratory insufficiency caused by central and/or mixed apneas and periodic breathing.

Description

The Company has delegated the responsibility for utilization management activities for the following sleep disorder testing and positive airway pressure therapy services and supplies to AIM Specialty Health® (AIM).
AIM uses its Clinical Appropriateness Guidelines for Sleep Disorder Management to determine medical necessity for sleep disorder testing and positive airway pressure therapy services and supplies and to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resources include:
  • Academy of Sleep Medicine
  • Agency for Healthcare Research and Quality
  • American Academy of Family Physicians
  • American Academy of Otolaryngology—Head and Neck Surgery Foundation
  • American Academy of Pediatrics
  • American College of Physicians
  • American Thoracic society
  • Canadian Agency for Drugs and Technologies in Health

References


AIM Specialty Health®. AIM Clinical Appropriateness Guidelines for Sleep Disorder Management. 2019. [AIM Web site]. 02/09/2020. Available at: http://www.aimspecialtyhealth.com. Accessed 09/09/2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)


95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Follow AIM Guidelines for medical necessity


HCPCS Level II Code Number(s)


A4604 Tubing with integrated heating element for use with a positive airway pressure device

A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028 Oral cushion for combination oral/nasal mask, replacement only, each

A7029 Nasal pillow for combination oral/nasal mask, replacement only, pair

A7030 Full face mask used with a positive airway pressure device, each

A7031 Face mask interface, replacement for full face mask, each

A7032 Replacement cushion for use on a nasal application device mask interface, replacement only, each

A7033 Pillow for use on a nasal cannula type interface, replacement only, pair

A7034 Nasal interface (mask or cannula type) used with a positive airway pressure device, with or without head strap

A7035 Headgear used with a positive airway pressure device

A7036 Chin strap used with a positive airway pressure device

A7037 Tubing used with a positive airway pressure device

A7038 Filter, disposable, used with a positive airway pressure device

A7039 Filter, nondisposable, used with a positive airway pressure device

A7044 Oral interface used with a positive airway pressure device, each

A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, only

E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0561 Humidifier, non-heated, used with positive airway pressure device

E0562 Humidifier, heated, used with positive airway pressure device

E0601 Continuous positive airway pressure (CPAP) device

E1399 Durable medical equipment, miscellaneous

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 saturation

G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels



Revenue Code Number(s)

N/A



Coding and Billing Requirements



Policy History

Revisions from 07.03.05w
02/09/2020This version of the policy will become effective 02/09/2020. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 02/09/2020. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:
    • Added chronic narcotic use as a contraindication to APAP.
    • Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension.

07.03.05v
06/29/2019This version of the policy will become effective 06/29/2019. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 06/29/2019. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:
  • Criteria were moved for patients with established CSA and combined under one indication: BPAP with and without back-up rate feature.
  • The condition to try rate support for central sleep apnea to align with clinical practice was removed.

07.03.05u
03/01/2018This version of the policy will become effective 03/01/2018.

The following policy has been revised to communicate the Company’s delegation of precertification/preapproval of home-based sleep studies to AIM Specialty Health® (AIM).

The following CPT code has been removed from this policy:
95803

The following HCPCS code has been removed from this policy:
A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified

All ICD-10 CM codes have been removed from this policy.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 02/09/2020
Version Issued Date: 02/10/2020
Version Reissued Date: N/A



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