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July 2015

Clarification: Clinical guidelines for re-titration studies, APAP treatment

About a titration study

During a titration study, the sleep team calibrates a sleeping patient’s CPAP device to ensure the right amount of air pressure. CPAP is a common treatment used to manage sleep-related breathing conditions, such as obstructive sleep apnea.

As you may know, Blue Cross Blue Shield of Michigan requires preauthorization for in-lab titration studies. These studies are performed once it’s determined that a patient will need treatment with a continuous positive airway pressure, or CPAP, device.

Preauthorization is also needed for re-titration, or a repeat study, for patients who are already being treated with a CPAP device, but who have a recurrence, worsening of symptoms or poor response to treatment.

If, after evaluating the patient, a board-certified sleep medicine physician believes a new titration study is clinically appropriate, the physician must submit a preauthorization request to AIM Specialty Health®. AIM will approve an in-lab repeat titration if the clinical guidelines are met. In-lab sleep studies performed solely as routine procedures or to determine employment status are not considered medically necessary.

As part of the sleep study preauthorization program, AIM makes available its clinical guidelines to assist providers in determining whether an in-lab sleep study, including a re-titration study, is appropriate for a patient. AIM’s clinical guidelines, however, are not intended to be an exhaustive list of all the medical reasons for an in-lab sleep study. Under the “Add More Information for Sleep” section on AIM’s ProviderPortalSM board certified sleep medicine physicians have the opportunity to provide additional medical information to support the need for in-lab testing.

If a preauthorization request is not immediately approved, this does not necessarily mean the request will be denied. Instead, the case may require further review by an AIM physician to make a determination. This includes evaluating all additional information provided on the ProviderPortal or through peer-to-peer discussions with an AIM sleep physician.

Note: FEP® is excluded from the preauthorization requirement.

APAP titration or treatment
In situations where the request for a new in-lab re-titration study for a CPAP user cannot be immediately approved, the sleep physician should not assume that we are instead suggesting re-testing with an automatic positive airway pressure, or APAP, device. If AIM determines an in-lab titration is not medically necessary, then an APAP titration or APAP treatment is also considered unnecessary. As such, Blue Cross will not cover the cost of the APAP rental, and the sleep physician should not ask a durable medical equipment supplier to provide an APAP machine for free.

Want more information?
For additional information on AIM’s sleep management program or to get answers to clinical questions, click here.** To register with AIM or access its ProviderPortal, visit AIMSpecialtyhealth.com.**

**Blue Cross Blue Shield of Michigan does not own or control the content of this website.

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