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Health Plans | Utilization Management


Since 2008 EviCore's Sleep solution has offered an end-to-end solution for the episode of care for sleep apnea diagnosis and treatment as well as for ongoing compliance with treatment. Our solution manages the utilization of sleep diagnostic procedures and positive airway pressure (PAP) therapy devices and supplies on the front end of a diagnosis, and works to improve long-term adherence to PAP compliance on the back end. In addition, EviCore can help health plans identify high-quality providers of diagnostic testing and PAP therapy.      

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Sleep Diagnostics

EviCore currently manages medical necessity review and prior authorization (PA) for both attended- facility sleep studies and home sleep testing (HST). In the application of our Sleep solution, requests are evaluated against our evidence-based clinical guidelines and meet one of three outcomes:

  • Approved if clinical guidelines are met
  • Redirected to an HST if the clinical guidelines for attended polysomnography (PSG) are not met, but the criteria for a HST are met
  • Denied if the information supplied does not meet criteria for any procedure.
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CPT codes for Sleep Studies

  • Facility-based baseline PSG for adults (95807, 95808, 95810) and children (95782)
  • Split-night studies (95811)
  • Facility-based PAP titration for adults (95811) and children (95783)
  • Multiple sleep latency testing (95805)
  • Home sleep testing (95800, 95801, 95806, G0398, G0399, G0400)
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Sleep Apnea PAP Therapy

EviCore can manage all durable medical equipment (DME) PAP therapy codes and supplies through medical necessity review and PA. Our PAP therapy program consists of four parts: initial PAP usage, confirmation of compliance with PAP therapy, PAP replacement machines, and ongoing resupply of PAP equipment. Our Sleep solution manages all of the following codes for PAP therapy: 
•    CPAP and APAP Devices (E0601)
•    Bi-level PAP Devices (E0470, E0471)
•    PAP Therapy Masks and Supplies (A7027 – A7046)
•    PAP Therapy Humidifiers (E0561, E0562)

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TherapySupport PAP Compliance

EviCore’s system for monitoring participating members’ compliance with PAP therapy is called TherapySupportSM.  TherapySupportSM collects PAP usage and intervenes with DME and physician providers when patients are not meeting targeted usage levels. When a patient is not compliant with PAP therapy, a sleep educator contacts the DME provider and/or the treating physician to support effective treatment of obstructive sleep apnea. Our system enables health plans to efficiently obtain real-time, objective assessments of patient adherence to therapy.

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Clinical Guidelines

EviCore’s evidence-based Sleep solution clinical guidelines are based upon major society guidelines and practice parameters, as well as national and international associations. In addition, peer-reviewed literature, major treatises, input from health plans, and practicing academic and community-based physicians are also utilized in the construction of our guidelines. EviCore’s Sleep clinical guidelines undergo an annual review process to ensure they reflect the latest evidence-based medicine.

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American Academy of Sleep Medicine (AASM)

The American Academy of Sleep Medicine (AASM) recently awarded EviCore’s evidence-based clinical guidelines for diagnostic testing for obstructive sleep apnea with 5 stars. Across the nine criteria used, the AASM scored EviCore the highest, indicating that its guidelines are the most in line with the standard. 

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Sleep SmartChoice

EviCore’s innovative SmartChoice for Sleep program is a member outreach service focused on those members that have been diagnosed with sleep apnea but have not yet started PAP therapy. SmartChoice agents educate these health plan members on available sleep apnea treatment options and can get them scheduled with a DME provider. By working with these members, SmartChoice helps patients to overcome barriers and get critical therapy started.

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Payment Integrity

Our integrated system Claims Studio delivers savings through an enhanced focus on accurate claims payment. The system can easily be made an extension of the client’s existing claims workflow.

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Claims Studio

Our proprietary integrated system, Claims Studio, delivers savings through an enhanced focus on accurate claims payment. The system can easily be made an extension of the client’s existing claims workflow.

Frequently Asked Questions

Yes. EviCore operates prior authorization programs for current clients that cover all sleep diagnostic studies. Prior authorization can be required for all attended sleep studies, home sleep studies, and home APAP titration. Our experience shows that programs that include prior authorization for both attended and home studies improve the continuity of care a patient receives by linking each step of the process.

Communication with providers occurs before the Sleep solution is implemented and written notifications are delivered after every request for services or devices is completed. 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. Both the health plan and EviCore use mailed letters, fax, or email to notify providers to attend these presentations. After 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, when it reaches a final determination (approved or denied) notification is immediately sent to the provider.

Philips Respironics is voluntarily recalling the below devices due to two (2) issues related to the polyester-based polyurethane (PE-PUR) sound abatement foam used in Philips Continuous and Non-Continuous Ventilators: 1) PE-PUR foam may degrade into particles which may enter the device’s  air pathway and be ingested or inhaled by the user, and 2) the PE-PUR foam may off-gas certain chemicals.  The foam degradation may be exacerbated by use of unapproved cleaning methods, such as ozone (see FDA safety communication on use of Ozone cleaners), and off-gassing may occur during initial operation and may possibly continue throughout the device’s useful life.  

Medical Device recall list

These issues can result in serious injury which can be life-threatening, cause permanent impairment, and/or require medical intervention to preclude permanent impairment. If you are a user of a product impacted by the recall, it is crucial  you contact your doctor to discuss whether or not you should stop using your machine and you register your affected Philips Respironics devices at the following site:

  1. Sleep Diagnostics − EviCore currently manages medical necessity review and PA for both attended sleep studies in a facility and home-based sleep testing (HST). In our programs, requests for attended sleep studies or HSTs are evaluated against our proven 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 TherapySupport, 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 utilization management (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.

TherapySupport℠ was the first system to market an established direct connectivity to the PAP therapy manufacturers’ device reporting databases. TherapySupport℠ 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.

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)
  • Bi-Level 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)
Sleep Insights
Clinical Expertise

One of the things that drew me to EviCore was the opportunity to develop the Sleep program, which at that time was in its early stages. At the time that I joined, there was significant overutilization of expensive facility-based sleep testing which was limited in availability, while less-expensive and easily available home sleep testing was significantly underutilized. This not only had a negative financial impact on the patient, but also a medical one in that delays in diagnosis and initiation of care was (sadly) the norm rather than the exception.  With our program not focusing on denials but rather redirections to the appropriate test for the right patient, we have succeeded in reversing this trend. When I was asked to be Chief of the Sleep solution, I was given the opportunity to further improve the provider’s web experience, expand our scope to help manage all forms of sleep apnea treatment, and also expand our patient outreach programs to improve patient access to testing and support of their therapy. While I may not interact with patients one-on-one anymore, I am able to provide a positive service to Sleep patients on a much larger scale, which is very gratifying.

Mark Ippolito

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