CurrentBlue Cross Blue Shield - MassachusettsPolicy 970
Carelon (formerly AIM) Sleep Disorder Management CPT, HCPCS and Diagnoses Codes
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Lists CPT and HCPCS codes in-scope for Carelon (formerly AIM) Sleep Disorder Management across Commercial and Medicare Advantage products and notes program-level prior authorization requirements and investigational status for select codes.
Policy Summary
PayerBlue Cross Blue Shield - Massachusetts
PolicyCarelon (formerly AIM) Sleep Disorder Management CPT, HCPCS and Diagnoses Codes
Policy CodePolicy 970
Change TypeAdded codesprior authorization requirement updated
Effective Date
Next Review Date
Key ActionObtain prior authorization for CPT 64568 when billed for obstructive sleep apnea (G47.33).
SourceLink
POLICY UPDATE CHANGES
Added CPT code 64568 and indicated prior authorization is required for obstructive sleep apnea (G47.33).
Added CPT Category III codes 0964T, 0965T, 0966T and K code K10727 (noting effective 10/1/2025).
Carelon (formerly AIM) name change noted.
6+Distinct HCPCS/CPT code tables included (BPAP, OSA oral appliances, APAP/CPAP, MSLT/MWT, PSG/HST, implants)
64568Implantation code newly added requiring prior authorization for OSA
0964T-0966TCategory III oral appliance/jaw expansion codes added
E0485HCPCS flagged investigational for Commercial and Medicare products
Coverage Criteria and Program Rules
Coverage criteria and program rules
Codes listed are in-scope for the Carelon Sleep Disorder Management Program; specific coverage and medical necessity are determined by Carelon Medical Benefits Management Clinical Guidelines and benefit contracts.
Medical necessity must be documented in the member's medical record; services are subject to audit and may be denied if documentation is insufficient.
Program scope
- CPT and HCPCS codes listed for Commercial Managed Care (HMO and POS), PPO and EPO are in-scope under the Carelon Sleep Disorder Management Program.
- CPT and HCPCS codes listed for Medicare HMO and PPO are in-scope under the Carelon Sleep Disorder Management Program.
Prior authorization is required for implantation code 64568 when billed for obstructive sleep apnea (G47.33).
HCPCS E0485 (prefabricated oral appliance) is considered investigational for Commercial and Medicare products and is not covered under this program.
For specific medical necessity criteria and product-specific determinations, refer to Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder.
Policy history notes
- Added CPT 64568 and indicated prior authorization is required for obstructive sleep apnea (G47.33) effective 2/2026.
Services and codes included in this list are governed by member benefit contracts; in-scope listing does not guarantee coverage without meeting medical necessity and benefit criteria.
CPT and HCPCS Codes
Bi-Level Positive Airway Pressure (BPAP) and accessoriesHCPCSCovered
| E0470 | Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with non-invasive interface (nasal or facial mask) |
| E0471 | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with non-invasive interface (nasal or facial mask) |
| E0561 | Humidifier, non-heated, used with positive airway pressure device |
| E0562 | Humidifier, heated, used with positive airway pressure device |
Oral appliances for OSAmixedCovered
| 0964T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mechanism |
| 0965T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, non-fixed hinge mechanism |
| 0966T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, fixed hinge mechanism |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment |
| K1027 | Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment |
Prefabricated oral appliancesHCPCSNot Covered
| E0485 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment |
APAP/CPAP, sleep testing (MSLT/MWT, PSG, HST)mixedCovered
| E0601 | Single level continuous positive airway pressure device or auto-titrating continuous positive airway pressure |
| G0398 | Home sleep study 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 study 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 study with type IV portable monitor, unattended; minimum of 3 channels |
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness |
| 95782 | Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist |
| 95810 | Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist |
Implanted hypoglossal nerve stimulators and related cranial nerve stimulator codesCPTExperimental
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array |
| 64583 | Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator |
| 64584 | Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array |
| 64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator - Requires prior authorization for obstructive sleep apnea (G47.33) |
Investigational HCPCS — E0485
HCPCS codeE0485
DescriptionOral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, prefabricated, includes fitting and adjustment
Coverage stanceConsidered investigational / not covered for Commercial (HMO/POS), PPO, Indemnity and Medicare HMO/PPO Blue
ProgramIn-scope under Carelon Sleep Disorder Management coding tables but flagged investigational
Provider Actions and Authorization Requirements
Prior Authorization
Prior authorization required for CPT 64568 for OSA
Prior authorization is required when CPT code 64568 is billed for obstructive sleep apnea (diagnosis G47.33).
- Code: 64568 — Open implantation of cranial nerve neurostimulator electrode array and pulse generator.
- Diagnosis: G47.33 (obstructive sleep apnea) — prior authorization requirement applies when billed for this diagnosis.
Scope and Definitions
In-scope CPT and HCPCS codes for Carelon Sleep Disorder Management
Scope definitionCPT and HCPCS codes listed are in-scope for the Carelon Sleep Disorder Management Program for Commercial and Medicare Advantage products; medical necessity determined by Carelon Clinical Guidelines.
Key APAP/CPAP and testing codesE0601, G0398, G0399, G0400, 95805, 95782, 95810
BPAP and accessoriesE0470, E0471, E0561, E0562
Oral appliances (custom/jaw expansion)0964T, 0965T, 0966T, E0486, K1027
Prefabricated oral appliance (not covered)E0485
Implanted hypoglossal/cranial nerve stimulators64582, 64583, 64584, 64568 (64568 requires prior authorization when billed for OSA G47.33)
Policy Summary
PayerBlue Cross Blue Shield - Massachusetts
PolicyCarelon (formerly AIM) Sleep Disorder Management CPT, HCPCS and Diagnoses Codes
Policy CodePolicy 970
Change TypeAdded codesprior authorization requirement updated
Effective Date
Next Review Date
Key ActionObtain prior authorization for CPT 64568 when billed for obstructive sleep apnea (G47.33).
SourceLink
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