REVIEW REQUEST FOR
Diagnosis of Sleep Disorders
Provider Data Collection Tool
Based on:
Medical Policy Reference
Manual 2.01.18
Medical Policy
MED.00002
Provider Tool Effective Date: 3/16/2011
Policy Last Review Date: Jan 2010
Policy Effective Date 4:2010
Policy Last Review Date: 11/18/2010
Policy Effective Date: 01/01/2011
Individual’s Name:
Date of Birth:
Insurance Identification Number/HCID:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Date/Date Range of Service:
Service Requested (CPT/HCPCS if known):
Office Fax Number:
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
Sleep Laboratory Polysomnography (check all that apply)
Witnessed Apnea
Habitual snoring
Epworth sleepiness scale greater than 10
Unexplained hypertension
Obesity (BMI greater than 35kg in adults or greater than 90th percentile for weight/height ratio in children)
Craniofacial or upper airway soft tissue abnormalities, including adnotonsillar hypertrophy, or neuromuscular disease
Individual with nocturnal symptoms suggestive of a sleep-related breathing disorder or other wise are suspected of
having sleep apnea with significant comorbidities (check all that apply):
Moderate or severe congestive heart failure
Stroke / transient ischemic attack
Coronary artery disease
Significant tachycardia
Bradycardic arrhythmias
Other ______________
Other: ____________________
Repeat Sleep Laboratory Polysomnography (check all that apply)
Adult with apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) of 15 or more events per hour
Adult with AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with (check
all that apply)
Symptoms of excessive daytime sleepiness
Impaired cognition
Insomnia
Mood disorders
Hypertension (documented)
Ischemic heart disease
History of stroke
Other ______________
Child with apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) of at least 5 per hour
Child with AHI or RDI of at least 1.5 per hour with (check all that apply):
Symptoms of excessive daytime sleepiness
Behavioral problems
Hyperactivity
Other ______________
Failure of resolution of symptoms or recurrence of symptoms during treatment
Assess efficacy of surgery or oral appliances/devices
Re-evaluate the diagnosis of OSA and need for continued CPAP (check all that apply):
Significant change in weight
Change in symptoms suggesting CPAP should be re-titrated or possibly discontinued
Other ______________
Other ___________________
Home or Portable Polysomnography (check all that apply)
Individual is an adult
Individual is a child (less than 18 years of age)
Study performed using Type 3 monitoring devices including (check all that apply):
Ventilation or airflow (at least 2 channels of respiratory movement or respiratory movement and airflow)
Heart rate or ECG
Oxygen saturation
Other(s) (please list all):
Study requested as an alternative to standard polysomnography
Individual has severe clinical symptoms highly suspicious for obstructive sleep apnea, where initiation of treatment is felt
to be urgent and standard polysomnography is not readily available
Individual is unable to be studied in a sleep laboratory
Study is for follow up after the diagnosis has already been established by standard polysomnography and therapy
initiated
To confirm diagnosis of obstructive sleep apnea in an individual with a high pretest probability of moderate to severe
obstructive sleep apnea based on the presence of the following (please check all that apply)
Habitual snoring
Epworth sleepiness scale greater than 10
Obesity (BMI greater than 30)
Witnessed apnea
No evidence of a significant medical comorbidity (e.g. CHF, chronic pulmonary disease, neuromuscular
disease, obesity hypoventilation syndrome)
No suspicion of other sleep disorder (e.g. narcolepsy, central sleep apnea, or periodic limb movement disorder,
restless leg syndrome).
Repeat Home or Portable Polysomnography (check all that apply):
Assess efficacy of surgery or oral appliances/devices
Re-evaluate the diagnosis of OSA and need for continued CPAP (check all that apply):
Significant change in weight
Change in symptoms suggesting CPAP should be re-titrated or possibly discontinued
Other:
Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing
Request is for Multiple Sleep Latency Testing (MSLT)
Request is for Portable Multiple Sleep Latency Testing in home setting
Request is for Maintenance of Wakefulness Testing
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Test is for any of the following conditions (check all that apply):
Evaluation of narcolepsy
Evaluation of suspected idiopathic hypersomnia
Routine diagnosis of obstructive sleep apnea
Follow up after treatment of sleep related disorders
Evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia),
including but not limited to, insomnia, circadian rhythm disorders and Shift Work Sleep disorder (SWSD)
Other:
Other: ____________________
“NAP” Study
Study performed for screening purposes
Study performed as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy
Other: ____________________
Actigraphy and Static Charge Sensitive Bed
Study will be performed as the sole method for diagnosis or evaluation of obstructive sleep apnea
Other: ____________________
Other
Request is for Diagnostic Audio Recording, with or without pulse oximetry, to document sleep apnea
Request is for Topographic Brain Mapping
Request is for acoustic pharyngometry (Eccovision™ Acoustic Pharyngometer®)
Other:
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
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