CommercialAdministrativeMedium impact
07.03.05ac, Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
Independence Blue Cross·Sleep Medicine, Pulmonology, Internal Medicine +1 more·Medical Policy
Effective date
Sep 19, 2026
We identified it
Sep 22, 2026
Summary
Independence Blue Cross has updated policy 07.03.05ac to delegate sleep disorder testing and PAP therapy utilization management back to Carelon Medical Benefits Management (previously delegated to AIM Specialty Health). Six procedure codes (CPT 95800, 95801, 95806 and HCPCS G0398, G0399, G0400) have been removed from the policy. The policy emphasizes requirements for standard written orders, proof of delivery, and adherence to Carelon's Clinical Appropriateness Guidelines for medical necessity determination.
Action Required
By September 19, 2026: (1) Billing team must remove CPT codes 95800, 95801, 95806 and HCPCS codes G0398, G0399, G0400 from system edits and stop billing these codes under this policy. (2) Update internal workflows to route all home-based sleep study utilization management requests to Carelon Medical Benefits Management instead of AIM Specialty Health. (3) Verify all sleep disorder testing and PAP therapy claims (CPT 95782, 95783, 95805, 95807 and HCPCS A4604, A7027-A7032) include: timely provider-signed standard written orders on file, contemporaneous proof of delivery/member receipt documentation, and medical necessity justification aligned with Carelon's Clinical Appropriateness Guidelines (available at https://guidelines.carelonmedicalbenefitsmanagement.com/current-sleep-guidelines). (4) Providers must obtain prior approval from Carelon Medical Benefits Management for facility-based sleep disorder testing and PAP therapy services before service delivery. (5) Update claim submission protocols to ensure all documentation requirements are met before billing to avoid denials. Failure to comply with documentation and utilization management delegation requirements will result in claim denials.