Are referrals needed for office visits to a sleep medicine specialist?
A referral is needed, based on the members benefit plan, for any office visits related to the sleep study that occur both before and after the sleep study.
When is a Prior Approval Required for Sleep Studies?
Prior Approval is always required for sleep studies.
How often may a sleep study be performed?
Based on clinical criteria, patients may be approved for sleep studies twice per year.
How do I know what sleep study related procedures and tests are considered experimental or investigational?
The following procedures are considered not medically necessary and are regarded as investigational:
- Palatal implant or stiffening procedures.
- Electro-sleep therapy.
- Laser-assisted uvulopalatoplasty.
- Radiofrequency tissue-volume reduction somnoplasty for upper airway obstruction.
- Tongue suspension/suturing procedures.
- Hypoglossal stimulators.
EmblemHealth's medical guidelines provide detailed information on procedures considered experimental or investigational.
Once a member is diagnosed with sleep apnea, how often should the member revisit the sleep medicine specialist?
There is no specific frequency limit or recommendation for follow-up visits. Additional visits should be as clinically indicated.
Upon diagnosis, who is responsible for ordering the initial supplies?
The Sleep Medicine specialist or the member's Primary Care Physician orders the initial supplies. The initial request is processed by an EmblemHealth DME nurse as the humidifier and the CPAP or Bi-PAP machine require authorization. All other supplies such as tubing and masks do not require authorization.
Who is responsible for ordering maintenance supplies?
Maintenance supplies are processed by a DME vendor based on the benefit schedule for the member's benefit plan or suggested replacement schedule for CPAP and Bi-PAP supplies.
For more information, review the full medical guidelines.