REVIEW REQUEST FOR
Diagnostic Sleep Study: ADULT (19 Years or Older)
Provider Data Collection Tool Based on Sleep Disorder Management Diagnostic & Treatment Guidelines
Policy Last Review Date: 01/01/2013
Policy Effective Date: 01/01/2013
Provider Tool Effective Date: 04/01/2013
Member Name:
Health Insurance Number:
Individual completing this form:
Date of Birth:
Requesting Provider Name:
NPI Number:
Phone Number:
Fax Number:
Ordering Provider Name (if different than above):
NPI Number:
Phone Number:
Fax Number:
Servicing Provider Name (if different than above):
NPI Number:
Phone Number:
Fax Number:
Contact phone:
Date of Service:
Place of Service:
Service Requested- Diagnostic Sleep Study (CPT/ HCPC):
Diagnosis:
Home
Outpatient Facility
Office
Other:
Diagnosis code:
1) If Place of Service is Office or Outpatient Facility, are there any contraindications to a Home
Sleep Test?
NO- there are no contraindications to a Home Sleep Test. Go to Section 2
YES- there are contraindications to a Home Sleep Test (check all that apply) & then go to Section 2
18 years of age or younger
Moderate/ Severe COPD
Moderate/ Severe CHF
Cognitive impairment
Neuromuscular impairment
Suspicion of sleep disorder other than OSA:
_________________________
Previous technically suboptimal home sleep test (2 nights attempted)
Previous home sleep test did not diagnose OSA, patient still clinically suspicious of OSA
Oxygen dependent
History of CVA within past 30 days
History of ventricular fibrillation
History of ventricular tachycardia
Other:
2) Has this patient previously had a sleep study?
NO
YES
Proceed to Section 3
Proceed to Section 4
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REVIEW REQUEST FOR
Diagnostic Sleep Study: ADULT (19 Years or Older)
Provider Data Collection Tool Based on Sleep Disorder Management Diagnostic & Treatment Guidelines
Policy Last Review Date: 01/01/2013
Policy Effective Date: 01/01/2013
Provider Tool Effective Date: 04/01/2013
3) NO previous sleep testing
Category
Apnea Events
Signs/ Symptoms
Co-morbid conditions
Please check all that apply:
Patient has observed apnea during sleep:
Yes
No
Unknown
Excess daytime sleepiness evidenced by:
Epworth Sleepiness Scale > 10, OR
Inappropriate daytime napping (during conversation, driving, eating), OR
Sleepiness that interferes with daily activities (not explained by other
causes)
Habitual snoring, or gasping/ choking episodes associated with wakening
Unexplained hypertension
Soft tissue abnormalities or neuromuscular diseases involving the craniofacial area
or upper airway
Obesity (BMI >30) BMI:
Height:
Weight:
Neck circumference >17” for males and > 16” for females
Previous stroke, more than 1 month ago
Transient Ischemic Attack (TIA)
Coronary Artery Disease (CAD)
Sustained supraventricular tachycardic arrhythmias
Sustained supraventricular bradycardic arrhythmias
4) Repeat/ Follow-up sleep testing
Category
Clinical History
Please check all that apply:
Patient has had oropharyngeal surgery to treat OSA
Patient has had significant weight loss (>10%) since the diagnosis of OSA/ most
recent sleep study
Patient has been using an oral device for treatment of OSA
Other:
*I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan
or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the
information reported on this form.
Name & title of person completing form
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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