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UHC Preauthorization requirements


Obstructive sleep apnea (OSA) is a treatable form of sleep disordered breathing. OSA affects at least 2% to 4% of the adult population and is increasingly recognized by the public.The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, to guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment.


Until recently, diagnosing OSA required an overnight stay in a specialized sleep laboratory, hospital or clinic with a standard laboratory polysomnography (PSG). UnitedHealthcare and its affiliates have recently reviewed the clinical evidence and technologic advancements relating to sleep testing and concluded there are a number of smaller, portable systems that can be used for selected patients at home.These portable sleep testing systems have made sleep apnea testing more convenient and cost-effective.

UnitedHealthcare is working with provider network to help members get tested for OSA more comfortably in their own homes, when appropriate. As a result, the following changes will be implemented:

Effective October 1, 2011: Oxford, UnitedHealthcareWEST (formerly known as PacifiCare) and Neighborhood Health Partnership members will continue to require preauthorization for all sleep studies.The current authorization process to add a site-ofservice determination based on medical necessity criteria.The criteria are available in the entityspecific policies for; Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders.

Effective October 1, 2011: River Valley members will now require preauthorization for all sleep studies. A site-of-service determination will be made in accordance with medical necessity criteria.The criteria are available in the River Valley policy: Polysomnography and
Portable Monitoring for Evaluation of Sleep Related Breathing Disorders.This policy is available online and accessible as outlined below.

Precertification/Preauthorization Process

The standard preauthorization/precertification process applies. Policy-specific details:

• The ordering physician is responsible for obtaining the preauthorization.

• Claims for services that require prior authorization which are lacking an authorization will be denied.

• Precertification/Preauthorization must be requested for the following Current Procedural Technology (CPT®) codes 95800, 95801, 95805,

95806, 95807, 95808 and 95810, 95811, and HCPCS codes G0398, G0399 and G0400.

(Note: CPT® 95803, actigraphy testing, remains not covered as a
stand alone procedure.)

• To help identify patients for whom a sleep test is appropriate and to determine the appropriate site of service, providers will be required to submit a patient information worksheet with their request for authorization.

• Based on the medical necessity criteria, many patients will be eligible for the study to be conducted in their own home.

• Patients who meet the indications for a sleep test, but are not appropriate candidates to be tested at home, will be authorized for a facility-based sleep test in a contracted sleep facility.

• Requests for in-laboratory polysomnography will be denied if the patient is eligible for home sleep testing.

Reference: Changes to Precertification Guidelines for Polysomnography and Portable Monitoring for Sleep Related Breathing Disorders for Oxford, UnitedHealthcare WEST (formerly known as PacifiCare), Neighborhood Health Partnership and River Valley Members

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