Why UHC 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 UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
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 UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- AASM Clinical Practice Guidelines for Sleep Apnea
- CMS NCD for Sleep Testing
Relevant CPT Codes
Specialty: Pulmonology / Sleep Medicine
Want the full strategy?
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