CurrentBlue Cross Blue Shield - MassachusettsPolicy 969

Carelon (formerly AIM) Sleep Disorder Management

Governs prior authorization and utilization management delegation to Carelon for sleep disorder diagnostic and treatment services (CPAP, BPAP, APAP, oral appliances, polysomnography, home sleep testing, MSLT, MWT) for BCBSMA commercial and Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCarelon (formerly AIM) Sleep Disorder Management

Policy CodePolicy 969

Change TypeNo material change

Effective DateSep 1, 2019

Next Review Date

Key ActionRequest prior authorization from Carelon for inpatient sleep disorder services and verify member eligibility before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1delegated utilization manager (Carelon formerly AIM)

requiredprecertification for inpatient services

requiredprior authorization for Medicare Advantage

severalrelated policies

Coverage and Medical Necessity Rules

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General medical necessity governance

Coverage and medical necessity are determined according to the Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder Diagnostic and Treatment.

Delegation and scope: Carelon is delegated to manage utilization for sleep disorder diagnostic and treatment services for BCBSMA; specific medical necessity criteria for CPAP, BPAP, APAP, oral appliances, polysomnography, home sleep testing, MSLT and MWT are in the Carelon guidelines.

See referenced Carelon guidelines for detailed criteria.

Coverage is subject to the member's applicable benefit contract; specific benefits may vary by product and/or employer group. Providers should refer to the appropriate member materials (for example, the Benefit Handbook or Certificate of Coverage) for member-specific benefit information.

Certain older BCBSMA sleep disorder management policies were retired effective September 1, 2019 and replaced by the Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder Diagnostic and Treatment. This policy does not enumerate explicit "not medically necessary" items; instead, historical BCBSMA policies (listed in the source) were retired and Carelon's guidelines now define medically necessary indications.

Prior Authorization, Documentation, and Audit Requirements

Prior Authorization

Prior Authorization Required for Inpatient Services

For services in this policy, precertification/preauthorization is required when the procedure is performed inpatient for all products. Ordering clinicians should verify member-specific requirements and obtain authorization as applicable.

Inpatient services: Precertification/preauthorization required for all products.

Prior Authorization

Outpatient Prior Authorization May Be Required (Product-Dependent)

Outpatient prior authorization requirements vary by product. Commercial Managed Care (HMO and POS), Commercial PPO and EPO may require prior authorization through the BCBSMA Sleep Management Program via AIM Specialty Health; requirements are member-specific. Ordering clinicians should verify eligibility and precertification requirements via Online Services (Provider Central) and request prior authorization from Carelon Medical Benefits Management when applicable.

Commercial Managed Care (HMO and POS): prior authorization may be required for outpatient services.
Commercial PPO and EPO: prior authorization may be required for outpatient services via the BCBSMA Sleep Management Program (AIM).
Medicare Advantage: prior authorization through Carelon Medical Benefits Management is required.

Step Therapy

No step therapy requirements are specified for sleep disorder management services in the source guidance.

Denial Risk

Documentation and Audit — Denial Risk

Member medical records must document that services are medically necessary. BCBSMA may audit services provided to members; all documentation must be available upon request. Failure to produce requested records may result in denial or retraction of payment.

Medical records must document medical necessity.
BCBSMA reserves the right to audit services regardless of provider participation status.
Failure to provide requested documentation may result in denial or retraction of payment.

Policy Background and Delegation

This policy delegates utilization management for sleep disorder diagnostic and treatment services to Carelon Medical Benefits Management (formerly AIM). Carelon is responsible for review and determination of medical necessity for services including CPAP, BPAP, APAP, oral appliances, polysomnography, home sleep testing, MSLT and MWT per the Carelon Clinical Guidelines. Providers must follow Carelon's prior authorization processes where required and ensure member medical records document that services are medically necessary; BCBSMA reserves the right to audit services and documentation and failure to produce requested records may result in denial or retraction of payment.

Referenced Guidelines and Definitions

Carelon Clinical Guidelines — reference

Guideline nameCarelon Medical Benefits Management Clinical Guidelines for Sleep Disorder Diagnostic and Treatment

ScopeDefines medical necessity criteria for sleep disorder management including CPAP, BPAP, APAP, oral appliances, polysomnography, home sleep testing, MSLT and MWT

Use in this policyPrimary source for determining coverage and medical necessity for sleep disorder diagnostic and treatment services delegated to Carelon

Referenced sectionsManagement of Obstructive Sleep Apnea (OSA), Oral Appliances, CPAP, APAP, BPAP, Polysomnography, Home Sleep Testing, MSLT and MWT

How to applyFollow Carelon guideline criteria when requesting prior authorization and when evaluating medical necessity for sleep-related services