Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Sleep apnea refers to sleep‐disordered breathing due to the recurrent collapse of pharyngeal tissues resulting in snoring, fitful sleep, and daytime somnolence. Risk factors for Obstructive Sleep Apnea (OSA) include male gender, age, obesity, airway characteristics, familial/genetic predisposition, smoking, and alcohol consumption. The majority of patients with OSA are asymptomatic, unaware of their sleep disordered breathing and associated health risks.
Note: Diagnosis and treatment of sleep apnea may be used only for care of a condition accepted on the claim. Sleep apnea is unlikely to be related to any occupational injury or disease and is therefore not expected to be an accepted condition on an L&I claim.
Condition of Coverage
- Adults, age 18 years and older;
- State approved providers;
- Consistent with the Medicare national coverage determination of Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) and Sleep Testing for OSA excluding Coverage with Evidence Development (CED). Complete information is on the CMS website;
- Consistent with the Medicare Local Coverage Determination (L30731) for Surgical Treatment of OSA. Complete information is on the CMS website;
- Any additional sleep apnea diagnosis and treatment referenced as non-covered in Medicare national and local coverage decisions are not covered.
Background Policy Information
The State Health Technology Clinical Committee (HTCC) reviewed sleep apnea diagnosis andtreatment in adults on March 16, 2012. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that sleep apnea diagnosis and treatment in adults are covered benefits with conditions. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority.
Implementation of Determination
Diagnosis and treatment of sleep apnea may be used only for care of a condition accepted on the claim. Sleep apnea is unlikely to be related to any occupational injury or disease and is therefore not expected to be an accepted condition on an L&I claim. All requests require prior authorization.