Why Aetna Denies Sleep Study (Polysomnography)
Home sleep test not attempted first
Epworth Sleepiness Scale not documented
Symptoms do not meet criteria for in-lab study
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 ESS score and clinical symptoms
Note comorbidities requiring in-lab study (CHF, COPD, neuromuscular disease)
If home test failed or was inconclusive, document results
Reference BMI and neck circumference
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
- AASM Clinical Practice Guidelines for Sleep Apnea
- CMS NCD for Sleep Testing
Relevant CPT Codes
Specialty: Pulmonology / Sleep Medicine
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