Predetermination Request for Lab-Based Sleep Study (Home Sleep Studies and Auto-Titration do not require review)

Blue KC will provide coverage for Sleep Studies when it is determined to be medically necessary.

Predetermination for sleep study is not required for patients age of 6 or under.

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* Required Field

Enter Patient Information

  • Review Type:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • IDC-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • CPT or HCPCS Codes: *
    (Include modifiers if applicable)
  • CPT/HCPCS codes must contain 5-9 charactersUnits may contain up to 3 characters
    Units:
  • Date of Service/Admission Date: *

* Required Field

Enter Provider Information

  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*
  • Provider ID OR NPI: *
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
  • Ordering Physician's Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:
  • Facility/Supplier Name: *
  • Facility NPI:
  • Facility/Supplier Address: *
  • Facility/Supplier City: *
  • Facility/Supplier State: *
  • Facility/Supplier Zip: *

Specify code for Lab Sleep Study to be performed:

FEP Members—Review Required:

  • 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  • 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
  • 95800 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

No Review Required:

  • 95081 Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)
  • 95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)
  • G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
  • G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
  • G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels (Investigational)
  • 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist—FEP Members: Review Required; see FEP Members section.
  • 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist—FEP Members: Review Required; see FEP Members section.
  • 95800 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist—FEP Members: Review Required; see FEP Members section.

Review Required:

  • 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
  • 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
  • 95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
  • 95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  • 95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist
  • Yes No
  • Is this a repeat study?
  • * If yes, date of last study:

If yes, please attach a copy of the last sleep study. *

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  • Yes No
  • Was the last study unattended? *
  • Yes No
  • Is this a CPAP titration/re-titration? * If yes, why?

For a diagnosis of obstructive sleep apnea (OSA), indicate which symptoms are present.

  • Yes No
  • Habitual snoring *
  • Yes No
  • Observed apneas *
  • Yes No
  • Excessive daytime sleepiness *, Epworth Sleepiness Score:
  • Yes No
  • Body mass index (BMI) greater than 50 *

Does the member have any of the following?

  • Yes No
  • Central sleep apnea *
  • Yes No
  • Congestive heart failure (CHF) *
  • Yes No
  • Chronic pulmonary disease (i.e., severe or uncontrolled asthma, COPD, sarcoidosis) *
  • Yes No
  • Obesity hypoventilation syndrome *
  • Yes No
  • Narcolepsy *
  • Yes No
  • Periodic limb movements in sleep *
  • Yes No
  • Restless leg syndrome *
  • Yes No
  • Complex sleep apnea *
  • Yes No
  • Cataplexy *
  • Yes No
  • Sleep paralysis *
  • Yes No
  • Hypnagogic/hypnopompic hallucinations *
  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

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Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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