Obstructive sleep apnea services
Priority Health Medicare coverage is determined by the Centers for Medicare and Medicaid Services (CMS); if a coverage determination has not been adopted by CMS, our medical policy applies.
Obstructive sleep apnea (OSA) is characterized by the collapse and obstruction of the upper airway during sleep, leading to sleep fragmentation. In this syndrome, respiratory efforts persist but are ineffective due to obstruction that may occur anywhere in the upper airway.
- Obstructive Sleep Apnea - 91333
Obstructive sleep apnea services coverage
Home testing and diagnosis services, sleep studies, and various treatments such as continuous positive airway pressure (CPAP) are covered benefits when criteria are met. This may include uvulopalatopharyngoplasty (UPPP), uvulectomy, or other procedures to correct obstructive sleep apnea. See the criteria in the medical policy.
Surgical procedures may be subject to non-standard cost-sharing, depending on the member's plan.
If/when commercial employer group and MyPriority® individual plans cover certain surgeries, these surgeries may be covered at a different cost-sharing level than our standard benefit coverage levels.
To verify member cost sharing and coverage, use the Member Inquiry tool and look in the Additional benefits drop-down menu for Certain surgeries benefit information.
OSA services authorizations
Authorization is required:
- In-center sleep testing
- Capped rental positive pressure appliances
Participating providers use the Auth Request online authorization tool.
Non-participating providers use the authorization forms.
Authorization is not required:
- Home sleep testing
- Surgery that meets the medical necessity and criteria in the medical policy
- CPAP supplies and oral appliances, unless DME/P&O dollar threshold exceeded (greater than $1,000; $500 for Priority Health Medicaid).
OSA services billing
See the medical policy for codes that may apply and codes not covered.