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Sleep Management

Prior authorization requirements for sleep testing and treatment

For these services, we require prior authorization for all commercial  and Medicare Advantage members. Authorization is not required for Federal Employees Program (FEP) members.1

  • Home sleep test (HST)
  • Initial and ongoing treatment orders for DME and supplies related to sleep therapy: APAP, CPAP, BPAP
  • In-lab sleep study (PSG)
  • Titration study
  • Oral appliances for sleep therapy

How to submit a prior authorization request

Carelon Medical Benefits Management is the company that administers the prior authorization program for us. Carelon uses our medical policies to identify the clinical appropriateness of home or lab testing:

  • Sleep Disorder Management (969)
  • Sleep Disorder Management CPT and HCPCS Codes (970)
  • Medicare Advantage High Tech Radiology and Sleep Disorder Management (923)

On our medical policy site, search for "sleep."

Ordering clinicians

Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact Carelon to request prior authorization:

  1. Through a direct link on this site (no additional registration is required). In the eTools tab, go to Carelon. Click the Go Now button.
  2. Go directly to the Carelon ProviderPortal (registration is required) Note: If you’ve already registered for the ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.
  3. Call Carelon’s Contact Center at 1-866-745-1783
    • Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, Carelon will respond the next business day.

Free-standing labs, hospitals, and DME vendors 

Check with Carelon to make sure an authorization is in place before rendering services. Authorization for ongoing sleep therapy supplies will be dependent on member utilization of the equipment. The DME vendor will be required to provide utilization data to Carelon when requesting authorization for ongoing treatment. 

1. For FEP, prior approval is required for sleep studies performed in a location other than the home. Fax prior authorization requests to us at 1-888-282-1315.