Medical Policy Revision: Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Effective May 1, 2019, Horizon BCBSNJ will change the way we process certain professional and facility claims based on revisions to our medical policy, Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome.

Access our Medical Policy Manual to review this medical policy content.¹

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) or Medicare Advantage (MA) plans will be processed as follows.

• Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT® code 21085.
  
  Following our review, the services represented by this code may be denied as not medically necessary.

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ commercial or ASO plans will be, based on the submitted diagnosis code(s), processed as follows.

• Information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 95800, 95801, 95806 or HCPCS codes G0398, G0399, G0400 when rendered to patients age 18 and older.
  
  Following our review, the services represented by these codes may be denied as not related to the submitted diagnosis code(s).
   
• Information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 95810 or 95811.
  
  Following our review, the services represented by these codes may be denied as not medically necessary.
   
• CPT codes 95800, 95801, 95806 or HCPCS codes G0398, G0399, G0400 included on claims for services rendered to patients age 18 and older may be denied as not related to the submitted diagnosis code(s).
   
• CPT codes 95782, 95783, 95810 or 95811 included on claims for services rendered to patients of any age may be denied as not related to the submitted diagnosis code(s).

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ MA plans will be, processed as follows.

• Regardless of the submitted diagnosis code(s), HCPCS code E0485 will be denied as not medically necessary.
   
• Based on the submitted diagnosis code(s), HCPCS code E0486 may be denied as not medically necessary.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims on and after May 1, 2019.

CPT® is a registered mark of the American Medical Association.

¹ The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.