MPTAC review. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. You also avoid the insurance requirements of treatment compliance. MPTAC review. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. American Academy of Sleep Medicine. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. The machine is returned to the doctor the following morning for data analysis. Positive Airway Pressure (PAP) Supplies - Regence Respicardia Announces Highmark Coverage for the rem <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> 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. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. American Academy of Sleep Medicine (AASM). This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. 2007; 16(2):213-216. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Am J Respir Crit Care Med. 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. PDF FEP Medical Policy Manual - FEP Blue A trial with CPAP has failed or is contraindicated; The device is prescribed by a treating physician; The device is custom-fitted by qualified dental personnel; There is absence of temporomandibular dysfunction or periodontal disease. 2007; 1:1-8. Payment will be made for the rental of a PAP device for the first three (3) months (rental period) from the original start date of therapy, when the above clinical criteria are met. Littner M, Hirshkowitz M, Kramer M, et al. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. These coverage types are separate from one another. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. endobj Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. Nasal EPAP devices (e.g., Provent, Theravent) are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. 3 0 obj Liners are not interfaces for use with a PAP mask. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. 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). J Clin Sleep Med. Medical policy list | Blue Shield of CA Provider Your daily habits and environment can significantly impact the quality of your sleep. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. Standards of Practice Committee of the American Sleep Disorders Association. Available at: Morgenthaler T, Alessi C, Friedman L, et al. Polysomnography (PSG) also typically includes electrocardiography and monitoring of These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. of the following criteria are met: Throughout the PAP device rental period, the DME supplier must check that the member is compliant with use of the device. There is additionally a vital hereditary component to the disease. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Hypertension Programs and resources to help you prevent and manage hypertension. A liner used in conjunction with a PAP mask is considered a comfort and convenience item and is considered a non-covered item or service. stream 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. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Coverage continues if your sleep apnea improves with the CPAP treatment. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Hypertension 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. More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. Sleep. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Conley S, Knies A, Batten J, et al. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. 2005; 128(4):2166-2175. Replacement of PAP Devices Pediatr Clin North Am. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Most machines record your use for you. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 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. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and The terms of your CPAP machine, insurance coverage depends on your provider. Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. Version 2.6. Following are a list of Blue Cross Blue Shield North Carolina plan types and whether they cover bariatric surgery: Weight Loss Surgery for Health Plans Through Your Work References were updated. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. % Click the button below to submit your insurance information to us and get started! Effective April 01, 2023. 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. 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 equipmentandmeetALLof the following criteria: Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA whenALLof the following criteria are met: Payment will be made for the rental of a PAP device for the first three (3) months (rental period) from the original start date of therapy, when the above clinical criteria are met. Ann Intern Med. Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. Medical Policy & Technology Assessment Committee (MPTAC) review. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Practice Parameters for the Indications for Polysomnography and Related Procedures. BCBS of Kansas, which covers approximately 560,000 members.. Continuous positive airway pressure (CPAP): This is a noninvasive treatment for OSA that involves delivery of pressurized air during sleep through a device that snugly covers the nose. It happens when the muscles in the throat relax and block the air passages to make sure . 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 Once the 13 months have passed, you own the machine. Replacements of PAP devices for members with an existing diagnosis of OSA do not need a compliance chip if documentation of previous compliance, (i.e., compliance chip, telemonitoring, computer software), has been confirmed in the medical record. An American Academy of Sleep Medicine Report. Flemons WW. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. However, none of these portable tests currently provide diagnostic information that is superior to established Type III home portable monitors (HPM), which monitor and record a minimum of four parameters: respiratory movement/effort, airflow, ECG/heart rate, and oxygen saturation. Additionally, nap sleep is not physiologically the same as nighttime sleep and does not adequately reflect the range of sleep phases required for proper diagnosis, therefore, results are not accurate when compared to the current standard of a full polysomnography (PSG). compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. 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. 2004; 8(3):611-630. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: 2003, 26(7):907-913. Sleep Disorder Management Program - Horizon Blue Cross Blue Shield of Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . But don't worry - our team will handle the legwork in getting them to your insurance company. <> Marino M, Li Y, Rueschman MN, et al. for the American Academy of Sleep Medicine. Available at: Berry RB, Quan SF, Abreu AR, et al. Breathing Problems during Sleep. Risk factors for obstructive sleep apnea in adults. No other changes were made to statements or criteria. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. 2011; 7(5):531-548. Seen as youll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. ** Medical Management of Obstructive Sleep Apnea Syndrome The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Other insurance providers may have different standards. BlueCross BlueShield of South Carolina Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Policy effective 05/2022 Effective 05/2022 - 84% BlueCross BlueShield of Vermont Sleep Disorders Diagnosis and Treatment Policy effective 04/01/2022 Effective 04/01/2022 - 69% Blue Cross Blue Shield of Wyoming If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. Westchester, IL: American Academy of Sleep Medicine; 2007. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. 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. This limits your coverage options, and you may not get the exact product you desire. Payment will be made for the purchase of the device when There are a number of optional accessories you can purchase for your CPAP machine. Blue Cross and Blue Shield Kansas is an independent licensee of the Blue Cross Blue Shield Association Contains Public Information Populations Interventions Comparators Outcomes Individuals: With suspected obstructive sleep apnea Interventions of interest are: Limited channel home sleep apnea testing Comparators of interest are: Products or services advertised on this page may be offered by an entity that is affiliated with us. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. 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. Easy Breathe is one of the only online CPAP providers able to bill insurance. Blue Cross Sleep Apnea Coverage - HealthySleepClub.com Payment will be made for the purchase of the device whenBOTHof the following criteria are met: Throughout the PAP device rental period, the DME supplier must check that the member is compliant with use of the device. Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. American Academy of Pediatrics (AAP). Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline. Types of coverage. Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. This change affects all providers that manage sleep-related care for . However, this information is provided without warranty. Sleep Disorders. Want to read more about all our experts in the field? Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis. PDF Blue Cross Blue Shield of Michigan Medical Policy Beginning November 1, 2020, we have a contracted network of dental providers with American Academy Dental Sleep Medicine (AADSM) certification to supply custom fitted sleep appliances (E0486) that are prescribed by a specialist in sleep disorders and authorized by our Utilization Management department according to the clinical guideline for coverage. The exclusion of obstructive sleep apnea (OSA) as the predominant cause of sleep-associated hypoventilation; For BPAP-ST, the ruling out of CPAP as effective therapy if OSA is a component of the sleep-associated hypoventilation; Significant improvement of the sleep-associated hypoventilation with the use of either PAP device on the settings that will be prescribed for initial use at home, while breathing the individual's prescribed FIO2. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Save my name, email, and website in this browser for the next time I comment. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Inspire Medical wins coverage from five more BCBS plans Sleep Apnea Diagnosis and Medical Management - Blue Cross NC Indications for treatment of obstructive sleep apnea in adults. Providers have the opportunity to review . 2021 cpaphackers.com | All rights reserved. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Masks often cost $100 or more, and other equipment ranges between $20 and $100. 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. Practice parameters for using polysomnography to evaluate insomnia: an update. MPTAC review. Medical Policy | Blue Cross and Blue Shield of Illinois AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual or greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention). 2007; 137(5-6):97-102. 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. The Rationale, Definitions and References were updated. 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. Collop NA, Anderson WM, Boehlecke B, et al. Netzer NC, Stoohs RA, Netzer CM, et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. New Policy for Obstructive Sleep Apnea (OSA) and Sleep Devices J Clin Sleep Med, 2018; 14(7):1231-1237. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. American Academy of Sleep Medicine (AASM). PAP devices may improve quality of life in individuals with sleep apnea in adults. Be sure to check your insurance policy to determine your specific requirements. 2017; 13(3):479504. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. Fargo, N.D., 58121. Your email address will not be published. Sleep. The two main types of sleep apnea are: Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. 3 months/90 days. 4510 13th Ave. S. Coverage | BlueCross BlueShield of South Carolina PDF Medical Policy - Sleep Disorders, Diagnosis and Medical Management Please refer to the members contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. is found to be more effective in the sleep lab to be . These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Clin Chest Med. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Most CPAP machines cost between $500 and $800. 4 0 obj Pediatrics. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Learn more. Sleep. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. It isnot intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . Inspire Medical Systems - creator of a pacemaker-like system to treat obstructive sleep apnea - said today that the Blue Cross Blue Shield Association's Evidence Street issued a positive . Be aware that if you decide to stop CPAP treatment and decide later that you want to try the treatment again, your insurance company may require you to re-qualify for coverage. An American Sleep Disorders Association Report. Typically, you need a referral for a sleep study in order to receive coverage. An AHI/RDI greater than 30 is consistent with severe OSA. Review your policy to learn about the requirements specific to your insurance provider. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. in an asymptomatic individual; More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). 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. MPTAC review. MPTAC review. 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. 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. endobj MPTAC review. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). These are not considered 'interfaces' as defined in this policy. 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. Silber MH. Olejniczak PW, Fisch BJ. Revisions also made to Coding section for clarification of MWT coding. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing.