Why Aetna Denies CPAP / BiPAP Equipment
Sleep study does not meet AHI threshold
Prior compliance data not submitted
Home sleep test required before in-lab PSG
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Document AHI >= 15 or AHI 5-14 with symptoms/comorbidities
Include sleep study interpretation by qualified physician
For replacement, show compliance data (>4 hours/night, >70% of nights)
Note clinical symptoms (excessive daytime sleepiness, hypertension, CHF)
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- CMS NCD for CPAP Therapy
- AASM Clinical Practice Guidelines
Relevant CPT Codes
Specialty: Pulmonology / Sleep Medicine
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