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Information Required for Obstructive Sleep Apnea MND Requests

We have reviewed voluntary pre-service medical necessity determination (MND) requests for sleep study services related to the diagnosis of obstructive sleep apnea and found that a majority of these requests do not include all the information required to make a final determination.

Our authorization of services, and our claim payment, will be delayed if we do not receive all required clinical information with the initial request for an MND.

When completing a request for an MND for sleep study services related to obstructive sleep apnea, please be sure to:

  1. Complete all fields on our Fax Medical Necessity Determination Request Cover Sheet, including:
  • Name and phone number of the ordering physician.
  • Place of service where the study is to be performed.
  • CPT-4 procedure code.
  • ICD-9 or ICD-10 diagnosis codes, etc.
  1. Include additional clinical and medical record information (including MD office notes) relevant to establishing the necessity of performing the sleep study, including details about:
  • Any comorbid medical conditions including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure.
  • Any previous home sleep testing that failed to establish the diagnosis of obstructive sleep apnea.
  • Symptoms of obstructive sleep apnea, such as patient obesity, snoring, sleepiness during the day, etc.
  • Symptoms of other sleep disorders, including central sleep apnea, periodic limb movement disorder (PLMD), insomnia, parasomnia, circadian rhythm disorders or narcolepsy.

If you have questions, please speak with a Physician Services representative at 1-800-624-1110 or an Institutional Services representative at 1-888-666-2535, Monday - Friday, 8 a.m. - 5 p.m., Eastern Time.

Review the medical policy online To review our medical policy, Diagnosis of Obstructive Sleep Apnea, access our online Medical Policy Manual, and search for and click Diagnosis of Obstructive Sleep Apnea Syndrome.

How to initiate an MND To initiate an MND request, please complete our Fax Medical Necessity Determination Request Cover Sheet and fax a completed copy to 1-888-608-1015 .

Published on: January 13, 2014, 04:56 a.m. ET
Last updated on: November 24, 2020, 23:18 p.m. ET