Managed Care and Sleep Medicine Denice Logan, DO, FACOI Regional Medical Director Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Disclosure • BCN Medical Director • Associate Professor Michigan State University CHM 2
Objectives • Be familiar with the indications per the medical policy for BCN members to have a HST. • Be familiar with the date for the change in the policy • Know an important prerequisite for an in facility PSG 3
Managed Care and Sleep Medicine • American Academy of Sleep Medicine accredited sleep center in US has increased fourfold over the past 10 years. • OSA still fails to be diagnosed or treated, suggesting inadequite resource numbers to meet the growing demands. • CMS reimbursement has been targeted to reduce healthcare expenditures mandating more efficient approaches for diagnosing and managing chronic diseases such as OSA. • Laboratory – based PSG may be access limiting or delayed. • HST may be able to address this access and delay. SLEEP, Vol. 35, No 6,2012
Sleep Test Optimization Programs: • United Health Care – No pre-authorization for HST-2012 • Humana – Facility based sleep studies • Aetna – no pre-authorization for HST • Amerigroup – NovaSom (pre-authorization) • Priority - No preauthorization for a HST unless testing by a Medicare certified participating provider with a Type III test device (then pre authorization is required) • Cigna – HST preauthorization required yes • Anthem BCBS – Preauthorization yes • BCN-HST preauthorization yes , PSG yes 5
Managed Care and Sleep Medicine • Changes for sleep management – July 1, 2013 • Pre-authorization for BCN commercial, BCN Advantage HMO-POS and BCN Advantage HMO • Adult members with symptoms of OSA without other co-morbidities that would interfere with the test results will require a HST, and if HST non diagnostic with a high probability of moderate to severe sleep apnea, will qualify for an in facility test • Providers will submit requests for clinical review of sleep studies to BCN on e-referral 6
Sleep Studies - BCN Provider Affairs Overview June 2013 What Changed? Sleep Studies continue to Tests available to members Board-certified sleep Providers must be require authorization. has increased: medicine physicians can be specifically contracted for Three auth forms instead on panel with or without sleep testing: Added unattended home of two: Night Hawk to interpret study (95806/G3099) New Fee Schedule home studies (home & Home Monitored Unattended Home Study Quality Standards monitored tests) Outpatient prior to outpatient study Special Payment Exhibit required based on clinical Home Unattended (new) criteria
Managed Care and Sleep Medicine • Indications for HST for OSA: • Age 18 or > • High Pretest probability of moderate to severe OSA • AASM-high pretest probability in moderate to severe OSA (adjusted neck circumference > 43cm (17inches) and the presence of excessive daytime sleepiness Epworth sleepiness scale >10) Ajusted neck circumference + 3cm (If habitual snorer) + 4cm (HTN present) + 3cm (if apnea, gasping, choking most nights) • The STOP-BANG criteria is included in the questionnaire, as questions which will score appropriately for consideration of the requested authorization. • No comorbid diagnoses which would interfere with ventilation or the patient’s ability to use the equipment or interfere with the interpretation of the test (Moderate to severe CHF, stroke with deficit affecting the airway or breathing, unstable Seizure Disorder, unstable Neuromuscular disorders, Narcolepsy, Parainsomnias, Unstable CAD, Central sleep apnea, obesity hypoventilation syndrome, Restless leg syndrome) • Observed apnea during sleep 8
• A combination of at least two of the following (A-E) – A. Excessive daytime sleepiness , inappropriate daytime napping while driving conversing or eating, or interference with daily not explained by other conditions – B. Habitual snoring, gasping/choking associated with awakenings – C. Unexplained HTN – D. Body mass index greater than 35kg/m2 – E . Craniofacial or upper airway soft tissue abnormalities 9
References • References: – CMS Revises Sleep Medicine CPT Codes. In: AASM Special Update. Darien, II, American Academy of Sleep Medicine, 2011 – Michigan Sleep Disorders Association Recommendation for Third – Party Payer Sleep Medicine Policy September 25, 2012 – Rosen, C Auckley D, Benca R, et al. A multi-site randomized trial of portable monitoring and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and management of obstructive sleep apnea. HomePAP study. Sleep 2010; 33 (Abstract supplement ) A173 – SLEEP, Vol 35, No 6, 2012 – Sleep Disorders, diagnosis and Medical Management Medical Policy- BCBSM/BCN 10
Questions? 11
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