CurrentBlue Cross Blue Shield - MainePolicy N/A

Bilevel positive airway pressure (BiPAP) prior authorization

Requirements for requesting prior authorization for BiPAP devices for members of Blue Cross Blue Shield - Maine, including needed documentation, clinical indications, and exclusions (SNAP/unattended studies).

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyBilevel positive airway pressure (BiPAP) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form and the sleep study summary (including AHI/RDI) to Anthem Utilization Management Services to request BiPAP.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearauthorization duration once approved

5-15AHI/RDI range needing extra documentation

6example supporting conditions

Coverage Criteria for BiPAP Prior Authorization

Initial authorization criteria

Covered when ALL of the following are met

Prior authorization and documentation

If AHI/RDI is 5-15: Provide documentation of at least one of: excessive daytime sleepiness; impaired cognition; mood disorders or insomnia; documented hypertension; ischemic heart disease; history of stroke.AHI/RDI 5-15
SNAP or unattended studies do not qualify; include documentation of failed CPAP when applicable.

Additional documentation requirements: Submit documentation of failed CPAP when BiPAP is requested because of CPAP intolerance or ineffectiveness; include a copy of the original sleep study summary with the AHI/RDI.

SNAP or unattended studies do not qualify for authorization.

SNAP studies and other unattended sleep studies do not qualify for prior authorization for BiPAP and should not be submitted as the primary sleep-study evidence to support a request for BiPAP.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyBilevel positive airway pressure (BiPAP) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form and the sleep study summary (including AHI/RDI) to Anthem Utilization Management Services to request BiPAP.

SourceLink

On This Page

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Key Indices and Coding Considerations

AHI/RDI — documentation requirements when AHI/RDI 5–15

Required action when AHI/RDI is 5–15Include documentation of at least one qualifying condition: excessive daytime sleepiness; impaired cognition; mood disorders or insomnia; documented hypertension; ischemic heart disease; or history of stroke.

Supporting documentation to submitSubmit the Prior Authorization Request Form with the sleep study summary that reports the AHI/RDI.

CPAP failure evidenceIf applicable, include documentation of failed CPAP with the original sleep study summary (with the AHI/RDI).

Study type exclusionSNAP studies or unattended studies do not qualify for authorization.

Authorization durationIf approved, authorization is valid for one year.

Provider Actions — Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required — Submit the completed Prior Authorization Request Form for BiPAP and the sleep study summary (include the AHI/RDI) to Anthem Utilization Management Services. Fax: 207-822-5203 or mail to Anthem Utilization Management Services, Inc., Medical Review Department, P.O. Box 999, Portland, ME 04104-0999. Authorization (if approved) is for one year (rent-to-purchase). If you have questions, visit anthem.com and navigate to medical policy MED.00002 for Maine providers.

Send completed Prior Authorization Request Form for BiPAP
Include sleep study summary with AHI/RDI
Fax: 207-822-5203 or mail to Anthem Utilization Management Services, Inc., Medical Review Department, P.O. Box 999, Portland, ME 04104-0999
Authorization (if approved) is for one year

Documentation Required

CPAP Failure Documentation

Documented failure of CPAP therapy is required to support coverage of BiPAP when applicable. Submit evidence of failed CPAP along with the original sleep study summary (with the AHI/RDI). Reminder: SNAP studies or unattended studies do not qualify.

Attach documentation of failed CPAP when BiPAP is requested after CPAP trial
Include original sleep study summary with AHI/RDI
SNAP/unattended studies are not acceptable

Documentation Required

Required Documentation

Required documentation — Complete the Prior Authorization Request Form for BiPAP and include the sleep study summary showing the AHI/RDI. If the AHI/RDI is 5–15, include documentation of at least one qualifying condition: excessive daytime sleepiness; impaired cognition; mood disorders or insomnia; documented hypertension; ischemic heart disease; or history of stroke. A complete copy of the sleep study is not required, but the study summary with AHI/RDI must be provided.

Prior Authorization Request Form for BiPAP
Sleep study summary with AHI/RDI
If AHI/RDI 5–15: include ≥1 qualifying condition (see list)

Denial Risk

Triggers for Denial

Triggers for denial — Requests may be denied if required documentation is missing or incomplete. Common denial triggers include failure to submit the sleep study summary with the AHI/RDI, failure to submit documentation of failed CPAP when applicable, use of SNAP/unattended studies, or omission of required qualifying condition documentation when AHI/RDI is 5–15.

Missing sleep study summary with AHI/RDI
No documentation of failed CPAP when applicable
Submission based on SNAP/unattended study
Missing qualifying condition documentation when AHI/RDI is 5–15

OpenPayer

Bilevel positive airway pressure (BiPAP) prior authorization

Coverage Criteria for BiPAP Prior Authorization

Key Indices and Coding Considerations

Provider Actions — Prior Authorization and Documentation

Background

Definitions