Medicare Advantage

Medical Policy

Carelon Medical Benefits Management (formerly AIM Specialty Health® (AIM)) Precertification/Preapproval for Sleep Disorder Testing; Positive Airway Pressure (PAP) Titration; and APAP, BiPAP, and CPAP Machines and Replacement Supplies for Medicare Advantage Members

For most members enrolled in the Company’s Medicare Advantage HMO and PPO products, the Company requires precertification/preapproval through Carelon Medical Benefits Management (formerly AIM Specialty Health® (AIM))
for the following services:

Sleep disorder testing, including multiple sleep latency testing (MLST), performed in the facility setting;

Positive airway pressure (PAP) titration performed in the facility or out of center settings;

APAP, BPAP, and CPAP machines and related supplies (eg, tubing, water chambers, face masks)

To direct the application of these services for our members, Carelon utilizes Medicare coverage guidance (eg, Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare coverage guidance exists, Carelon utilizes their Sleep Disorder Management Diagnostic & Treatment Guidelines.* For more information about the services and devices that require precertification/preapproval, refer to current version of medical policy #MA07.058: Sleep Disorder Testing and Positive Airway Pressure Therapy. Please note that sleep disorder testing performed in the out of center setting does not require precertification/preapproval through Carelon. The medical policy is used to determine medical necessity for this service.

*Carelon’s medical necessity guidelines are consistent with the clinical appropriateness criteria based on technology assessment, peer-reviewed medical literature including clinical outcomes research and consensus opinion in medical practice. To access the complete list of Carelon Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click here.

Issue Date: