Obstructive sleep apnea services

Applies to:

All plans

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.

Definition

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.

Medical policy

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.

Non-standard cost-sharing

If/when commercial employer group and MyPriority® individual plans cover certain surgeries, these surgeries are covered at a different cost-sharing level than our standard benefit coverage levels.

To verify member cost sharing, 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.

Also see: