Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. Pediatrics. 2003, 24(2):307-313. Government Agency, Medical Society, and Other Authoritative Publications: ActigraphyApnea/Hypopnea Index (AHI)Apnea Risk Evaluation System (ARES)Nap StudyObstructive Sleep Apnea (OSA)Pharyngometry AcousticQuantitative EEG MappingSleepStripSNAP Testing SystemStatic Charge Sensitive BedsTopographic EEG Mapping. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. - Comfort Products: Mask Liners, Creams, etc. The document header wording was updated from Current Effective Date to Publish Date. References were updated. Sleep. BOTH Liners are not interfaces for use with a PAP mask. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 2002; 347(7):498-504. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. E If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. 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 individuals physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. 2003, 26(7):907-913. However, how often they replace these, and how much of the cost your insurance covers, of course depends on your policy and the company youre with. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. 1. x\Ys~W5p8krxv~qL 4@q_y)N&Bee\>U?0fxywC]|59wo_^UQ^C?^x"/0>_|}yiEQ$5U+/_'~M*yIaaT)GT=r4K%8K^VAfy?WC}l[6~;pklytDRRUAXH,{["GowQmU^VqU0V3,0m0O~d]y Im{W(x9AdWq &KaFgE/ +S/`5UeW'~S#s_jsE;kym+//}1M'x Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 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 for the American Academy of Sleep Medicine. References and Coding sections were also updated. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Sleep. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Therefore, it is particularly important that individuals with severe OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: People with obstructive sleep apnea experience partial or complete closure of the upper airway during sleep, which can lead to snoring, gasping, or even choking. 2020; 172(5):325-336. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. Centers for Medicare and Medicaid Services. Collop NA, Anderson WM, Boehlecke B, et al. In order to be eligible for reimbursement, The Centers for Medicaid and Medicare (CMS) require proof that you are using the CPAP machine at least 4 hours per night, on 70% of nights, in a consecutive 30-day period. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Sleep Apnea. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. Chesson AL Jr, Berry RB, Pack A. ** Medical Management of Obstructive Sleep Apnea Syndrome A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Swiss Med Wkly. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based PSG or with a positive home/portable sleep test); AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual. PAP devices may improve quality of life in individuals with sleep apnea in adults. Available at: Morgenthaler T, Alessi C, Friedman L, et al. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. 2007; 16(2):213-216. You also avoid the insurance requirements of treatment compliance. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. MPTAC review. Technology Evaluation Center (TEC) assessments. American Academy of Sleep Medicine; Standards of Practice Committee. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). References were updated. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> There is no additional payment for liners used with a PAP mask. MPTAC review. Our site does not include the entire universe of available offers. Sleep. Pediatrics. If you're ready for more, sign up to receive our email newsletter! So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. This change was approved at the November 29, 2007 MPTAC meeting. 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. A7028. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Blue Care Network's medical policy on the diagnosis and management of obstructive sleep apnea includes coverage for home sleep studies for members with symptoms of OSA without other comorbid conditions. Adherence to therapy is defined as use of PAP greater than or equal to four (4) hours per night on 70% of nights during a consecutive 30-day period anytime during the first three (3) months of initial usage. First, you must have a prescription for CPAP therapy from your healthcare provider. Continued use beyond the first three (3) months of therapy. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Watanabe T, Kumano-Go T, Suganuma N, et al. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. The effective date is February 26, 2018. These coverage types are separate from one another. This difference in efficacy is more pronounced for individuals with severe OSA, as oral appliances have been shown to be less efficacious in individuals with severe OSA than they are in individuals with mild-moderate OSA. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. If your CPAP prescription mentions a Lifetime Need or says 99 months, this means that the prescription is valid for as long as you require the therapy. Medical policy list. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. JAMA. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. If you are on a rent-to-own structure, your monthly fee typically equals the cost of the CPAP machine divided by the number of rental months. BCBSNC will provide coverage for surgery for obstructive sleep apnea and upper airway resistance syndrome when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. 2002; 165(11):1499-1503. This is a unique virtual learning experience for health care professionals caring for women and . 2009; 5(3):263-276. 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. Mulgrew AT, Fox N, Ayas NT, Ryan CF. AHRQ Technology Assessment Program. 2000; 3(4):169-172. When you buy through our links, we may earn a commission. Available at: Thurnheer R, Bloch KE, Laube I, et al. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Policy Statement . The Definitions and References were updated. Darien, IL: AASM; 2020. American Academy of Sleep Medicine. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. The American Academy of Sleep Medicine (AASM) Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults, updated in 2009, stated: Actigraphy alone is not indicated for the routine diagnosis of obstructive sleep apnea (OSA) but may be a useful adjunct to portable monitors (PMs) when determining the rest-activity pattern during the testing period (Option) (Epstein, 2009). Monahan KJ, Larkin EK, Rosen CL, et al. 1997; 20(6):406-422. 4 0 obj SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). The reason for this is that CPAP devices are a class II medical device under FDA regulation, meaning you require a prescription in order to obtain one, and in order to get the prescription, you need to undergo a sleep study and have a board-certified sleep specialist physician interpret your results and prescribe CPAP treatment before you undergo CPAP therapy. The most common options include: Medicare may cover a 3-month trial of CPAP therapy, and they may cover it longer if your doctor documents in your medical record that you meet certain conditions regarding the use of the device and they claim that the CPAP therapy is helping you. Benefits Application This medical policy relates only to the services or supplies described herein. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Conley S, Knies A, Batten J, et al. Easy Breathe is one of the only online CPAP providers able to bill insurance. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Act now to earn free CME credits and helps advance maternal health in New Jersey. 2002; 109(4):e69. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. Here is what we need in order to verify your insurance coverage: After getting you a quote for your insurance benefits, Easy Breathe will help you contact your doctor's office for the following: These documents are needed in order to show medical necessity to your insurance company. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. Easy Breathe is one of the only online CPAP providers able to bill insurance. The term RDI was also corrected to be Respiratory Disturbance Index (not Distress index) and the measure known as RERAS was also added to this definition. (such as sleep studies, CT scans) . Review your policy to learn about the requirements specific to your insurance provider. According to the American Academy of Sleep Medicine (AASM), updated definitions of OSA severity are provided as follows: Mild OSA: AHI of 5-15, involuntary sleepiness during activities that require little attention, such as watching TV or reading; Moderate OSA: AHI of 15-30, involuntary sleepiness during activities that require some attention, such as meetings or presentations; Severe OSA: AHI of more than 30, involuntary sleepiness during activities that require more active attention, such as talking or driving (AASM, 2008). Additional appliances should be denied as not medically necessary. Sleep. The content on this website is for informational purposes only. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. The technique is based on the analysis of sound waves that are launched from a loudspeaker and travel along a wave tube into the subjects airways where they are reflected. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. 2017; 13(10):1199-1203. Want to read more about all our experts in the field? The medical records must also document objective findings of compliance information, (i.e. % Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. A positive airway pressure device (CPAP, BPAP-ST,) may be considered medically necessary for the first three (3) months of therapy for those individuals with central sleep apnea (CSA) that have had an attended polysomnogram, performed on stationary equipment and meet ALL of the following criteria: Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA when ALL of the following criteria are met: Intra-oral devices not meeting the criteria as indicated in this policy are considered not medically necessary. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation. Either a heated humidifier or a non-heated humidifier is eligible for use with a covered PAP device when prescribed by the treating physician to meet the needs of the individual. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. Save my name, email, and website in this browser for the next time I comment. 2003; 124(4):1543-1579. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. If youre diagnosed with sleep apnea and require CPAP therapy, its likely your insurance will cover the cost of the device, and the replacements required thereafter. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h 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. Not all insurance plans work the same way. 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. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. 1 0 obj The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. Click the button below to request a free, no-obligation verification. Ann Intern Med. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. JAMA. Smith MM, McCrae CC, Cheung JJ, et al. Am J Respir Crit Care Med. 3 0 obj stream Involuntary sleepiness during activities that require little attention, such as watching TV or reading. 1 0 obj Ann Intern Med. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. He has tested hundreds of mattresses and sleep products. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the individual may be switched to BiPAP; For whom BiPAP is found to be more effective in the sleep lab. Nasal Expiratory Positive Airway Pressure (EPAP). A provider's office can often get an immediate approval when they submit a request online. 2007; 3(7):737-747. 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. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Sleep Med Rev. Efforts are made to maintain reliable data on all information presented. Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life (QOL), productivity, and overall health. According to the MPTAC review. 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. Indications for treatment of obstructive sleep apnea in adults. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Young T, Skatrud J, Peppard PE. Costs for purchasing a machine outright can range anywhere from $250 to $1,000 or more, depending on where you live and the type of machine you need. Effective March 3, 2009. J Clin Sleep Med. Sleep. Yes! Hypertension For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. risk of central sleep apnea, (chronic use defined as use of opioids on most days per week for greater than 3 months) Obesity hypoventilation syndrome, defined as pCO 2 greater than 45 mm Hg and pO 2 less than 60 mm Hg on arterial blood gas. 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. American Sleep Disorders Association and Sleep Research Society. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. O'Driscoll DM, Foster AM, Davey MJ, et al. Individuals have failed a prior trial of CPAP. Obstructive sleep apnea. CPAP therapy is effective, but it can also be expensive. Some rental plans may include the cost of replacement equipment, which is something to bear in mind when comparing the cost of buying outright versus going with insurance. 2005; 128(4):2166-2175. obstructive sleep apnea (OSA) in adults is defined as either: The AASM classifies mild, moderate and severe OSA as: Internal Medical Policy Committee 3-16-2020 Annual Review-no changes, Internal Medical Policy Committee 11-19-2020, Internal Medical Policy Committee 9-21-2021 Coding update- Arch Dis Child. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. Information was added to the Rationale section regarding MWT, taken from the 2005 updated guideline on Practice Parameters for Clinical Use of MSLT and MWT from the American Academy of Sleep Medicine. Five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention); Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses) and. No. Your daily habits and environment can significantly impact the quality of your sleep. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Be sure to check your insurance policy to determine your specific requirements.
blue cross blue shield sleep apnea coverage
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