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Get Cigna Sleep Study Precertification Request Form 2013-2024

Leep ___ Insomnia ___ Choking or gasping during sleep ___ Nocturia ___ Frequent unexplained arousals ___ CARECENTRIX – CIGNA SLEEP MANAGEMENT PROGRAM 10/2/2013 Page 1 of 2 SLEEP STUDY PRECERTIFICATION REQUEST FORM cigna.sleepccx.com Phone: 877.877.9899 Fax: 866.536.5225 B. Co-morbid conditions (Recent supporting office notes required) Moderate to severe pulmonary disease /hypertension____ Uncontrolled CHF (Class III or IV) ____ Uncontrolled significant, persistent cardiac arrhythmia ___.

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