J Clin Sleep Med. Over-the-counter (OTC) or prefabricated intra-oral appliances to treat OSA are not considered to be appropriate therapy for OSA in any clinical situation and, therefore, are non-covered. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage These tests vary in the number and nature of sleep parameters that are measured, in order to gain an understanding of the conditions under which sleep disturbances occur. 2013; 36(11):1747-1755. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. D'Andrea LA. PDF FEP Medical Policy Manual - FEP Blue Clinical Practice Guidelines | Blue Cross and Blue Shield of Illinois Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. Your doctor will first check for symptoms of obstructive sleep apnea, including: If your symptoms indicate you might have obstructive sleep apnea, the next step is to take a sleep study. Updated coding: Added CPT code 95806 and 0089T; removed CPT codes 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145, 95806, 95808, 95810, 95811, 99508; removed ICD-9 Procedure codes 76.62, 76.63, 76.64, 76.65, 76.66, 89.17; removed HCPCS codes E0561, E0562, E0601, K0183, K0189, K0268, K0531, K0532, K0533, S8260, D7940, D7944, D7946, D7947, D7948, D7949, D7950, D7950, D7995, D7996, S2080, 0088T. 2008; 31(1):141-147. This document addresses selected services for the diagnosis of sleep disorders including: Investigational and Not Medically Necessary: Nap studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy. Respicardia Announces Highmark Coverage for the rem Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC Interpretation Obstructive Sleep Apnea (OSA) syndrome consists of a collection of symptoms including daytime sleepiness, fatigue, snoring, and restless sleep with a disrupted sleep pattern. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. MPTAC review. Positive Airway Pressure (PAP) Supplies - Regence Hypopnea: Breathing that is more shallow, and/or slower, than normal. MPTAC review. If your insurance company determines you are not using the machine frequently enough as per your policy, they may stop covering their portion of the machine rental. Hypertension Programs and resources to help you prevent and manage hypertension. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 2002; 165(11):1499-1503. Levenson JC, Troxel WM, Begley A, et al. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: Yes! endobj Payment will be made for the purchase of the device when <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> Nasal Expiratory Positive Airway Pressure (EPAP). Your daily habits and environment can significantly impact the quality of your sleep. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). Med Clin North Am. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. Payment may be made for one (1) appliance. Click the button below to submit your insurance information to us and get started! Typically, you need a referral for a sleep study in order to receive coverage. This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. 2010; 95(12):1031-1033. <> This change was approved at the November 29, 2007 MPTAC meeting. Criteria Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP) An APAP device or CPAP device may be considered medically necessary for the treatment of obstructive sleep apnea (OSA) in adults and covered as durable medical equipment when the following criteria are met: APAP Conley S, Knies A, Batten J, et al. 2 0 obj PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnea, as long as you meet the following requirements: You must also meet Medicares compliance requirements, which state that you must use the machine at least 4 hours per night, 70% of the time or more, during the first 3 months. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. You must also adhere to the same compliance requirements as Medicare recipients, namely using the machine at least 4 hours every night on 70% of nights. CPAP machine prices start around $250 and can reach $1000 or higher. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. 1. There is additionally a vital hereditary component to the disease. Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Close follow-up for PAP device usage and problems in individuals with sleep apnea by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems if needed. 4510 13th Ave. S. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. The cost you pay depends on your insurance coverage.In addition to the CPAP machine itself, you also need to pay for additional equipment such as filters, which run between $5 and $30, and masks, which can cost up to $100. . Apnea-Hypopnea index (AHI) or Respiratory disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. If the criteria are not met, the accessories are considered not medically necessary. Another type of sleep disturbance is simply known as apnea or central apnea. This condition, caused by problems in the central nervous system, is unrelated to OSA and is not addressed in this document. Sleep Management - Blue Cross Blue Shield of Massachusetts Along with key review factors, this compensation may impact how and where products appear across the site (including, for example, the order in which they appear). Updates to Sleep Apnea Corporate Medical Policy - Blue Cross NC Sleep. A position statement regarding MWT was added. Available at. American Academy of Sleep Medicine; Standards of Practice Committee. If you have any questions about the guidelines, or wish to provide feedback, this can be done by contacting the Quality Improvement Department at 312-653-3465. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from Treatment of Obstructive Sleep Apnea Procedure code: E0601 Background: Sleep Apnea Sleep apnea occurs when an adult stops breathing or has slowed breathing during sleep. MPTAC review. These coverage types are separate from one another. minimally invasive solutions for patients with obstructive sleep apnea, announced today that three new Blue Cross Blue Shield Association ("BCBSA") healthcare plans have issued positive coverage policies of Inspire therapy. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Breathing Problems during Sleep. Continued use beyond the first three (3) months of therapy Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Ann Intern Med. Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. The two main types of sleep apnea are: Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Best Anti-Snoring Mouthpieces & Mouthguards, CPAP: Continuous Positive Airway Pressure, Link Between Sleep Apnea and Heart Disease, Medical and Brain Conditions That Cause Excessive Sleepiness, Drowsiness or falling asleep while driving, You have an hourly AHI between 5 and 14 and a, AHI index between 5 and 14, along with a comorbidity related to obstructive sleep apnea; or. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Compliance monitoring equipment for CPAPs, APAPs, or BiPAPs (e.g., smart card, compliance chip, tele monitoring, and computer software) is considered an integral component of the function of the device and is not eligible for separate reimbursement. Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; The individual is experiencing success in treatment. That said, coverage varies depending on your plan, insurance company, and authorization requirements. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. These include: Insurance does not typically cover any products that are considered optional. Be sure to check your insurance policy to determine your specific requirements. Involuntary sleepiness during activities that require more active attention, such as talking or driving. 4 0 obj Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. Risk factors for obstructive sleep apnea in adults. Flemons WW, Littner MR, Rowley JA, et al. These are not considered interfaces as defined in this policy. Tubing with integrated heating element for use with positive airway pressure device. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. 1997; 20(6):406-422. Obstructive sleep apnea (OSA): This is a form of sleep disturbance, which occurs as the result of a physical occlusion of the upper airway during sleep, which interferes with normal breathing. Clin Chest Med. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. References and Coding were updated. MPTAC review. Well cover some of the most common insurance policies surrounding CPAP equipment. Arch Fam Med. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. 2017; 13(3):479504. Blue Cross Sleep Apnea Coverage - HealthySleepClub.com There are many different types of sleep-related disorders, including obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), insomnia, narcolepsy, nocturnal movement disorders, such as Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD), unexplained excessive daytime sleepiness, and arousal disorders (parasomnias). The members contract benefits in effect on the date that services are rendered must be used. After reading and interpreting the results of your sleep study, your doctor may diagnose you with sleep apnea and work with you to develop a treatment plan. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. 4 0 obj In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Central Sleep Apnea (CSA) is a serious breathing disorder that disrupts the normal breathing pattern during sleep and negatively affects quality of life and overall cardiovascular health. Not all insurance plans work the same way. An independent member of the Blue Shield Association 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome Original Policy Date: April 3, 2009 Effective Date: October 1, 2022 Section: 2.0 Medicine Page: Page 1 of 26 . The Eccovision Acoustic Reflection Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. 2019; 10:551. Polysomnography (PSG) also typically includes electrocardiography and monitoring of How Often Does Insurance Cover a New CPAP Machine? Again, this will depend on your individual insurance plan and provider, but in the case of Anthem they offer the following replacement schedule: Generally speaking, most insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Watanabe T, Kumano-Go T, Suganuma N, et al. This change affects all providers that manage sleep-related care for . For general information about AIM Specialty Health, call 1-847-564-8500, Monday through Friday, from 9 a.m. to 6 p.m., Eastern Time (ET). Before making a final decision, please read the Plan's federal brochure (RI 71-005). No other changes were made to statements or criteria. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. Sleep Disorder Management Program - Horizon Blue Cross Blue Shield of Portable Monitoring Task Force of the American Academy of Sleep Medicine. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. 1997; 20(12):1208. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. The application of each Blue Shield of California medical policy is subject to regulatory requirements and/or plan specific benefits and limitations (Evidence of Coverage - EOC). Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. Strollo PJ Jr. Practice parameters for using polysomnography to evaluate insomnia: an update. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. Otolaryngol Head Neck Surg. The machine attaches to a mask that you wear over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open. More expensive accessories often come with warranties of 1 to 3 years. In order to give you a prescription for a CPAP machine, your doctor must confirm that your sleep difficulties are caused by sleep apnea and not by another condition. Internal Medical Policy Committee 11-23-2021 Revised the way the not medically necessary statements were written; added Daytime electrical stimulation (eXciteOSA) of the tongue. Hypertension <> Review your policy to learn about the requirements specific to your insurance provider. endobj Sleep Disorders. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Our site does not include the entire universe of available offers. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. However, if the member is found to be using the PAP device as directed and is achieving the desired results, the DME supplier must contact the individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. 2004; 130(1):58-66. More advanced machines tend to cost more. The criterion standard diagnostic test for sleep disorders is a polysomnogram performed in a sleep laboratory.2 A standard polysomnogram includes EEG, submental electromyogram (EMG) and electrooculogram (to detect rapid eye movement [REM] sleep) for sleep staging. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. NCD #240.4.1. endobj Upper airway: The area of the upper respiratory system including the nose, mouth and throat. 1 0 obj While the use of actigraphy has been demonstrated to be useful in the detection of sleep problems in healthy or normal individuals, potential benefits for individuals with suspected sleep disorders have not been shown. Most CPAP machines cost between $500 and $800. Policy Statement . Filters, which need to be replaced frequently, run between $5 and $30 each. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. Our site receives compensation from many of the offers listed on the site. Tubing with integrated heating element for use with positive airway pressure device, Combination oral/nasal mask, used with continuous positive airway pressure device, each, Oral cushion for combination oral/nasal mask, replacement only, each, Nasal pillows for combination oral/nasal mask, replacement only, pair, Full face mask used with positive airway pressure device, each, Face mask interface, replacement for full face mask, each, Cushion for use on nasal mask interface, replacement only, each, Pillow for use on nasal cannula type interface, replacement only, pair, Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap, Headgear used with positive airway pressure device, Chinstrap used with positive airway pressure device, Tubing used with positive airway pressure device, Filter, disposable, used with positive airway pressure device, Filter, non-disposable, used with positive airway pressure device, Oral interface used with positive airway pressure device, each, Exhalation port with or without swivel used with accessories for positive airway pressure devices, replacement only, Water chamber for humidifier, used with positive airway pressure device, replacement, each, **Allowing for a three (3) month supply *Allows for a 10 day delivery before run-out.
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