Sleep Study Prior Authorization Form Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Facility NPI* 10 digitsFacility where Sleep Study being performed* Error Message Ordering MD* Date of Service (if known) MM slash DD slash YYYY Member's ID#*0 of 11 max characters Member's DOB* MM slash DD slash YYYY Name* First Last Error Message Provider InformationContact Name* Phone #*Fax #*Email address in order to receive confirmation of request receipt* Date of Service MM slash DD slash YYYY Clinical InformationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Member’s H/W/BMIEpworth Sleepiness Score Comorbid ConditionsTest Requested: CPT CODE* Example CPT code: 12345Check all that apply Attended full channel nocturnal polysomnography (NPSG)/laboratory sleep test (LST) Multiple sleep latency testing(MLST) (only for narcolepsy) Check all that apply AHI ≥ 40 in the first 2 hours CPAP nearly/eliminates respiratory events during non/REM sleep CPAP titration > 3 hours Reason for initial test in a Facility Pediatric/Adolescent Cardiac disease (CHF NYHA 3 or 4, uncontrolled arrhythmia, pulmonary hypertension,recent (6 months)MI) Chronic Pulmonary Disease- COPD requires oxygen, obesity hypoventilation, lung disease uncontrolled medical therapy Neurological d/o-previous CVA/TIA, nocturnal seizures, Parkinson’s , AML, neurodegenerative disorders Complex Sleep disorder Narcolepsy Parasomnias Periodic limb movement disorder Central sleep apnea BMI≥50 Previous home testing inconclusive Lack of mobility/dexterity Cognitive impairment Other Please Specify* Reason for repeat NPSG/LST Assess continued need for CPAP Assess because of failed APA/CPAP or symptom recurrence Failed split night NPSG Assess need to change settings for positive airway pressure Confirm the presence of OSA prior to upper airway surgery Other MD order attached* Attached Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Reset to re-sign.Signature Date Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Reset to re-sign.Signature Date* Comments Authorization is not a guarantee of payment CAPTCHA