Sleep: Overview

eviCore's Sleep solution provides cost-effective management of the diagnosis and treatment of obstructive sleep apnea and supports long-term therapy and disease-risk reduction, creating better outcomes for everyone. We developed our own evidence-based, proprietary criteria covering the diagnosis and treatment of sleep-disordered breathing and created the TherapySupportSM system to help support and improve patient compliance with PAP therapy.

  
  

Everyone benefits through better outcomes

  • Plans

    Our Sleep solution analyzes the patient’s therapy use and intervenes based on the results. By objectively reviewing the patient’s use of therapy and acting on the data analysis, our solution reduces plan costs and improves patient outcomes

  • Providers

    Our Sleep solution provides Durable Medical Equipment (DME) providers with valuable feedback regarding patient adherence and notifies them when patients reach their compliance goals.

  • Patients

    Our Sleep solution operates behind the scenes; it updates providers and clients on patient compliance with recommended treatments, and communicates with providers when patients struggle with therapy – so patients receive any needed provider attention or changes to DME.

  

Criteria & Easy Approval Process: Leading To Better Decisions

Nurse Review MD Review Peer to Peer Predictive Intelligence and Clinical Decision Support Appropriate Decision Web Phone Fax Methods of Intake REAL-TIME DECISION
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Educational Tools

Here you’ll find all the resources, tools, and links to know more about eviCore’s Sleep Solutions.

Educational Tools

  

The more we know, the better the outcome

A list of the most common Sleep Management queries is provided below. For more detailed information, visit the Contact Us page.

What is included in the Sleep solution?

1. Sleep Diagnostics − eviCore currently manages medical necessity review and PA for both attended sleep studies in a facility and home sleep testing (HST). In our programs, requests for attended sleep studies or HSTs are evaluated against our robust criteria.

2. Sleep Apnea PAP Therapy − eviCore can manage all durable medical equipment PAP therapy codes and supplies through medical necessity review and PA.

3. PAP Compliance − eviCore developed an innovative and effective system that monitors how well patients in sleep apnea treatment are complying with PAP therapy guidelines. Our system, called TherapySupportSM, objectively monitors PAP usage, and intervenes with DME and providers when patients are not meeting targeted usage levels.

4. Network Management − In addition to the UM of sleep diagnostics and therapy requests using evidence-based guidelines, the eviCore Sleep solution offers a network quality assessment and verification program as well as access to our sleep network. The goal of both approaches is to deliver high-quality providers of facility-based testing, home-based testing, and DME to our clients’ members.

5. IT infrastructure − The Sleep solution resides on the same IT platform as all other eviCore solutions. Our IT infrastructure offers a wide range of flexibility in application and can accommodate a more streamlined request process for those providers who have demonstrated an inclination to order procedures in accordance with evidence-based medicine.

Provide more details about TherapySupportSM.

TherapySupportSM was the first system to market an established direct connectivity to the PAP therapy manufacturers’ device reporting databases. TherapySupportSM is a quality-of-care and patient-support activity aimed at improving adherence to prescribed treatments and decreasing the effects of sleep apnea-related comorbidities.

What type of services are managed under your Sleep solution?

Currently, eviCore maintains clinical criteria for the following sleep procedures, PAP devices, and PAP supplies:

  • Facility-Based Polysomnography for adults (95807, 95808, 95810) and children (95782)
  • Split Night Studies (95811)
  • Facility-Based Titration for adults (95811) and children (95783)
  • Home Sleep Testing (95800, 95801, 95806, G0398, G0399, G0400)
  • Multiple Sleep Latency Testing (95805)
  • CPAP and APAP Devices (E0601)
  • Bilevel PAP Devices (E0470, E0471)
  • PAP Therapy Masks and Supplies (A7027 thru A7046, A4604)
  • PAP Therapy Humidifiers (E0561, E0562)
  • PAP Therapy Compliance
  • Oral Appliances (E0485, E0486, S8262)
How do you communicate with the patient’s provider?

Communication with referring providers occurs before the Sleep solution starts, and after every request; written notifications are delivered via major methods. In addition, we monitor patients undergoing PAP therapy for sleep apnea treatment, and our Sleep Educators communicate with the referring provider when the patient is not using therapy as prescribed.

Prior to the start of the Sleep solution, eviCore schedules webinars designed to communicate all elements of the Sleep solution to providers. Providers are notified by mailed letter, fax, or email by the health plan and eviCore to attend these presentations. Learning key facets of the solution, the providers are better equipped to secure authorizations for their patients.

In the medical necessity determination process, providers contact eviCore either by Web or phone to initiate requests for sleep diagnostic procedures, PAP therapy devices, and PAP therapy supplies. On the phone, providers or their staff speak with eviCore’s specially trained clinical decision support agents, who are specifically assigned to handle only sleep solution cases. Whether the case is completed on the phone or on the Web, once it reaches a final determination (approved or denied), notification is immediately sent to the provider.

Do you offer a mandatory prior authorization program for all sleep studies?

Yes. eviCore operates prior authorization programs for current clients that cover all Sleep Diagnostic study and PAP codes. Prior authorization can be required for all attended sleep studies, home sleep studies, home APAP titration, PAP therapy devices, and PAP therapy supplies. Our experience shows that programs that include prior authorization of both attended and home studies improve the continuity of care a patient receives by linking each step of the process.