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Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
MA07.058n
​

Policy

The Company has delegated the responsibility for utilization management activities for the following sleep disorder testing and positive airway pressure (PAP) therapy services and supplies to Carelon Medical Benefits Management with the exception of services performed in the emergency room or during an inpatient or observation unit stay.


For information on policies related to this topic, refer to the Cross References section in this policy.

Please refer to the References section of this policy for a link to applicable Local Coverage Determinations (LCD), National Coverage Determinations (NCD), or the entire Carelon Clinical Appropriateness Guidelines for Sleep Disorder Management, that are part of this program, as well as all applicable procedure codes.

Carelon first utilizes Medicare guidelines (e.g., LCD, NCD). If no Medicare guidelines exist, Carelon will utilize their Clinical Appropriateness Guidelines for Sleep Disorder Management to determine medical necessity for these services.​


  • Facility-based sleep disorder testing and PAP titration
  • PAP therapy
  • Supplies related to PAP therapy
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneously with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.​

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, sleep disorder testing and positive airway pressure therapy services and supplies are cove​red under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services and supplies are met.

However, services that are identified as not medically necessary or experimental/investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of single-level continuous positive airway pressure (CPAP), auto-adjusting positive airway pressure (APAP), and bi-level positive airway pressure (BPAP) for obstructive sleep apnea and/or respiratory insufficiency caused by central and/or mixed apneas and periodic breathing.

Description

The Company has delegated the responsibility for utilization management activities for the following facility-based sleep disorder testing and positive airway pressure therapy services and supplies to Misspelled WordCarelon Medical Benefits Management. To determine medical necessity for these services, Misspelled WordCarelon first utilizes Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare guidelines exist, Misspelled WordCarelon will utilize their Clinical Appropriateness Guidelines for Sleep Disorder Management to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resource​s include​:
  • Academy of Sleep Medicine
  • Agency for Healthcare Research and Quality
  • American Academy of Family Physicians
  • American Academy of Otolaryngology–​Head and Neck Surgery Foundation
  • American Academy of Pediatrics
  • American College of Physicians
  • American Thoracic Society
  • Canadian Agency for Drugs and Technologies in Health

References

Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Sleep Disorder Management. 2026. [Carelon Web site]. 09/19/2026.  Available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines. Accessed June 29, 2026.

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Coding

CPT Procedure Code Number(s)
95782, 95783, 95805, 95807, 95808, 95810, 95811
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
Follow Carelon Guidelines for medical necessity
HCPCS Level II Code Number(s)
A4604Tubing with integrated heating element for use with a positive airway pressure device
A7027Combination oral/nasal mask, used with continuous positive airway pressure device, each
A7028Oral cushion for combination oral/nasal mask, replacement only, each
A7029Nasal pillow for combination oral/nasal mask, replacement only, pair
A7030Full face mask used with a positive airway pressure device, each
A7031Face mask interface, replacement for full face mask, each
A7032
​​Cushion for use on nasal mask interface, replacement only, each​​
A7033Pillow for use on a nasal cannula type interface, replacement only, pair
A7034Nasal interface (mask or cannula type) used with a positive airway pressure device, with or without head strap
A7035Headgear used with a positive airway pressure device
A7036Chin strap used with a positive airway pressure device
A7037Tubing used with a positive airway pressure device
A7038Filter, disposable, used with a positive airway pressure device
A7039Filter, nondisposable, used with a positive airway pressure device
A7044Oral interface used with a positive airway pressure device, each
A7045Exhalation port with or without swivel used with accessories for positive airway devices, replacement only
A7046Water chamber for humidifier, used with positive airway pressure device, replacement, each
E0470Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0561Humidifier, non-heated, used with positive airway pressure device
E0562Humidifier, heated, used with positive airway pressure device
E0601Continuous positive airway pressure (CPAP) device


Revenue Code Number(s)
N/A


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Coding and Billing Requirements

Policy History


Revision from MA07.058n
09/19/2026

This version of the policy will become effective 09/19/2026.


Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Sleep Disorder Management.  These guidelines are available online at: 
https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines.​



Revision from MA07.058m
11/15/2025

This version of the policy will become effective 11/15/2025.


Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines are available online at: 
https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines.​


The following HCPCS narratives have been revised in this policy:
FROM:
A7032 Replacement cushion for use on a nasal application device mask interface, replacement only, each

TO:
A7032: Cushion for use on nasal mask interface, replacement only, each


FROM:
A7046: Water chamber for humidifier, used with positive airway pressure device, replacement, only

TO:

A7046: Water chamber for humidifier, used with positive airway pressure device, replacement, each​




Revisions from MA07.058l
10/20/2024

This version of the policy will become effective 10/20/2024.


Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines for Sleep Disorder Management.  These guidelines are available online at: 
https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines.




Revisions From MA07.058k:
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
09/10/2023

The version of this policy will become effective 09/10/2023.


AIM has changed their name to “Carelon Medical Benefits Management" effective 03/01/2023.



Carelon Medical Benefits Management (formerly AIM Specialty Health® (AIM)) has revised their Clinical Appropriateness Guidelines for Sleep Disorder Management.  These guidelines are available online at: 

https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines.


Revisions From MA07.058j:
09/11/2022

This version of the policy will become effective 09/11/2022.

​AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Sleep Disorder Management.  These guidelines are available online at: 

https://aimspecialtyhealth.com/wp-content/uploads/2022/03/Sleep-Disorder-Management-09-11-22.pdf.


Revisions From MA07.058i:
​06/16/2021

​The policy has been reviewed and reissued to communicate the Company's continuing position on Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies.​
07/18/2020The version of this policy will become effective 07/18/2020.
The policy has been updated to communicate change of the delegation of home-based sleep studies for utilization management activities from AIM Specialty Health® (AIM) back to the Company.
The following CPT codes have been removed from this policy: 95800, 95801 and 95806.
The following HCPCS codes have been removed from this policy: G0398, G0399 and G0400.

Revisions From MA07.058h:
02/09/2020This version of the policy will become effective 02/09/2020. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 02/09/2020. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:
  • Added chronic narcotic use as a contraindication to APAP.
  • Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension.

Revisions From MA07.058g:
06/29/2019This version of the policy will become effective 06/29/2019. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 06/29/2019. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:
  • Criteria were moved for patients with established CSA and combined under one indication: BPAP with and without back-up rate feature.
  • The condition to try rate support for central sleep apnea to align with clinical practice was removed.

Revisions From MA07.058f:
12/19/2018This policy has been reissued in accordance with the Company's annual review process.
03/01/2018This version of the policy will become effective 03/01/2018.

The following policy has been revised to communicate the Company’s delegation of precertification/preapproval of ouf-of-center sleep disorder testing to AIM Specialty Health® (AIM).

The following CPT code has been removed from this policy:
95803

The following HCPCS code has been removed from this policy:
A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified

All ICD-10 CM codes have been removed from this policy.

Revisions From MA07.058e:
11/10/2017This version of the policy will become effective 11/10/2017.

Place of service requirements updated for the following Current Procedure Terminology (CPT) codes: 95800, 95801 or 95806.

Revisions From MA07.058d:
10/14/2016The intent of this policy remains unchanged, but the documentation requirements for continued PAP therapy have been updated.
The following HCPCS code has been added to this policy: A9279.

Revisions From MA07.058c:
10/01/2016ICD-10 CM codes have been added to this policy:

N52.35: Erectile dysfunction following radiation therapy
N52.36: Erectile dysfunction following interstitial seed therapy
N52.37: Erectile dysfunction following prostate ablative therapy

The following ICD-10 CM narrative has been revised in this policy:
N52.39:
FROM: Other post-surgical erectile dysfunction
TO: Other and unspecified postprocedural erectile dysfunction

Revisions From MA07.058b:
10/01/2015ICD-10-CM codes have been added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.
​
The following ICD-10 CM codes have been added to this policy:

F10.182F10.282F10.982F19.21F51.01F51.02F51.03F51.09
F51.11F51.12F51.13F51.19F51.3F51.4F51.5F51.8
G47.10G47.11G47.12G47.13G47.14G47.19G47.20G47.21
G47.22G47.23G47.24G47.25G47.26G47.27G47.29G47.30
G47.31G47.32G47.34G47.35G47.36G47.39G47.50 G47.51
G47.54 G47.59 G47.61 G47.69 G47.8 N52.01N52.02N52.03
N52.1N52.2 N52.31N52.32N52.33N52.34N52.39N52.8
N52.9

Revisions From MA07.058a:
08/19/2015ICD-10-CM codes have been added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

The following ICD-10 CM codes have been added to this policy:
E66.2 F11.182 F11.282 F11.982 F13.182 F13.282 F13.982 F14.182 F14.282 F14.982 F15.182 F15.282 F15.982 F19.182 F19.282 F19.982 G47.33 G47.411 G47.419 G47.421 G47.429 G47.52 G47.53
2/15/2015The policy was updated to communicate the Company's decision to include precertification/preapproval of positive airway pressure (PAP) therapy and supplies and to delegate precertification/preapproval to AIM.

The title of this policy has been updated to Sleep Disorder Testing and Positive Airway Pressure Therapy. The previous title of this policy was Sleep Disorder Testing.

References to "home-based sleep testing" updated to "out of center sleep testing".

Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

Face-to-Face requirements with professional provider for identified items added to policy.

The following HCPCS codes have been added to this policy (all medically necessary):
E0470, E0471, E0561, E0562, E0601, E1399, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046

The following ICD-9 CM codes have been removed from this policy:
327.30 Circadian rhythm sleep disorder, unspecified
327.31 Circadian rhythm sleep disorder, delayed sleep phase type
327.32 Circadian rhythm sleep disorder, advanced sleep phase type
327.33 Circadian rhythm sleep disorder, irregular sleep-wake type
327.34 Circadian rhythm sleep disorder, free-running type
327.35 Circadian rhythm sleep disorder, jet lag type
327.36 Circadian rhythm sleep disorder, shift work type
327.37 Circadian rhythm sleep disorder in conditions classified elsewhere
327.39 Other circadian rhythm sleep disorder
327.8 Other organic sleep disorders
333.2 Myoclonus
780.54 Hypersomnia, unspecified
786.04 Cheyne-Stokes respiration

Revisions From MA07.058:
01/01/2015This is a new policy.
9/19/2026
9/21/2026
MA07.058
Medical Policy Bulletin
Medicare Advantage
No
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