<> Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Policy and Coverage Criteria for Commercial Products: . More advanced machines tend to cost more. You might be able to find direct-to-supplier CPAP manufacturers with lower prices than those available through your insurance plan, though be sure to check if these devices are approved by the FDA. Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Chest. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Front Psychiatry. First, your doctor must diagnose you with obstructive sleep apnea following an approved laboratory sleep study or an at-home sleep study, and give you a prescription for a CPAP machine. 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. Patient Page. 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. 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. J Clin Sleep Med. Diagnosis and management of childhood obstructive sleep apnea syndrome. A position statement regarding MWT was added. D'Andrea LA. Review your policy to learn about the requirements specific to your insurance provider. 1996; 11(2). This is because many insurance plans follow Medicares issued guidelines on the replacement of supplies.If your insurance coverage covers your CPAP on a rental basis, you may be wondering how long the rental period lasts. actigraphy, including use of static charge sensitive beds; diagnostic audio recording, with or without pulse oximetry to document sleep apnea; Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea; Actigraphy or static charge sensitive beds. When services are Investigational and Not Medically Necessary: Unlisted otorhinolaryngological service or procedure [when specified as acoustic pharyngometry] (Note: CPT code 92520 Laryngeal function studies; aerodynamic testing and acoustic testing is not considered appropriate for this service), Actigraphy testing, recording, analysis, interpretation, and report; (minimum of 72 hours to 14 consecutive days of recording), Unlisted neurological or neuromuscular diagnostic procedure [when specified as nap study], Topographic brain mapping [for evaluation of a sleep disorder]. Recommendations from other national entities may vary. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. 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. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. 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). Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Clin Chest Med. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Act now to earn free CME credits and helps advance maternal health in New Jersey. - Power Supplies: CPAP Power Cords and Batteries. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. 2003; 124(4):1543-1579. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. 2007; 3(7):737-747. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. for the American Academy of Sleep Medicine. Medically necessary criteria regarding Type III home portable devices were updated with information about newer models of the SNAP devices that are considered Type III devices. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. Monahan KJ, Larkin EK, Rosen CL, et al. 2001; 19(1):173-186. An AHI between 5 and 15 is considered mild, an AHI between 15 and 30 is moderate, and an AHI greater than 30 is severe. A7028. There are a number of optional accessories you can purchase for your CPAP machine. This means your doctor still needs to conduct a sleep study to give you a diagnosis. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Indications for treatment of obstructive sleep apnea in adults. 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. 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 . Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Sleep Disorder Management Program - Horizon Blue Cross Blue Shield of 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- Sleep Disorders. 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). This revised Medical Policy will apply to both professional provider and facility claims. Sleep Disorders. Subject: Sleep Testing - Florida Blue A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 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). Pediatrics. 1 0 obj Inspire Medical wins coverage from five more BCBS plans Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. 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. Chesson AL Jr, Berry RB, Pack A. There is additionally a vital hereditary component to the disease. 3 0 obj A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Young T, Skatrud J, Peppard PE. MPTAC review. MPTAC review. 2020; 172(5):325-336. CPAP machine prices start around $250 and can reach $1000 or higher. 2007; 146(3):157-166. 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. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Sleep. MPTAC review. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. 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 medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. These are not considered 'interfaces' as defined in this policy. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. 2004; 130(1):58-66. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome AASM | Payer Policy Scorecards Smith MM, McCrae CC, Cheung JJ, et al. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. If youre among the 2% to 9% of adults who suffer from obstructive sleep apnea, a CPAP machine may be the solution to better sleep. Devices Used for the Treatment of Sleep Apnea in Adults Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. 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. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. 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. Easy Breathe is one of the only online CPAP providers able to bill insurance. Olejniczak PW, Fisch BJ. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Arch Pediatr Adolesc Med. Wide deviations in the conditions and data collection methods available cause significant variability in the outcomes of these studies and do not allow for proper sleep assessment. m|(=IPYAcmAa#nhwRz(v^6;Ut4?o+UIv(($HSnG>:~;khOFtUG+'@Gq^B0kT$Ae/a#*lJk=aZdj~\:POhI-y p;6p=E?t:M?h=U,>) ]1r!!pr8lDbDadJJV|p6l-Dq. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Before making a final decision, please read the Plan's federal brochure (RI 71-005). 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. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. N Engl J 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. 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. This limits your coverage options, and you may not get the exact product you desire. Once the 13 months have passed, you own the machine. Am J Respir Crit Care Med. PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI Fargo, N.D., 58121. 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. 2007; 30(4):519-529. But don't worry - our team will handle the legwork in getting them to your insurance company. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Your doctor must determine which type of study is right for you. The use of specific product names is illustrative only. Hypopnea: Breathing that is more shallow, and/or slower, than normal. American Sleep Disorders Association and Sleep Research Society. Pediatr Clin North Am. 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. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and Benefits Application This medical policy relates only to the services or supplies described herein. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Sleep Apnea. endobj Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> Medical policy list | Blue Shield of CA Provider Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. 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. 2009; 5(3):263-276. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- 2007; 1:1-8. 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. Otolaryngol Head Neck Surg. Clinical practice. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Only 10% allow for more frequent replacement. 1997; 20(6):423-487. MPTAC review. Flemons WW, Littner MR, Rowley JA, et al. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 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. Annals Intern 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 individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. J Sleep Res. Tubing with integrated heating element for use with positive airway pressure device. The Rationale, Definitions and References have been updated. Want to read more about all our experts in the field? Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. 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. 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. This change affects all providers that manage sleep-related care for . 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. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. Breathing Problems during Sleep. The effective date is February 26, 2018. x\Ys~W5p8krxv~qL 4@q_y)N&Bee\>U?0fxywC]|59wo_^UQ^C?^x"/0>_|}yiEQ$5U+/_'~M*yIaaT)GT=r4K%8K^VAfy?WC}l[6~;pklytDRRUAXH,{["GowQmU^VqU0V3,0m0O~d]y Im{W(x9AdWq &KaFgE/ +S/`5UeW'~S#s_jsE;kym+//}1M'x Sleep. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. However, none of these portable tests currently provide diagnostic information that is superior to established Type III home portable monitors (HPM), which monitor and record a minimum of four parameters: respiratory movement/effort, airflow, ECG/heart rate, and oxygen saturation. Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Collop NA, Tracy SL, Kapur V, et al. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. 1999; 131(7):485-491. Sleep. Adherence to therapy is defined as use of PAP greater than or equal to four (4) hours per night on 70% of nights during a consecutive 30-day period anytime during the first three (3) months of initial usage. Sleep. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h BCBS of Kansas, which covers approximately 560,000 members.. Centers for Medicare and Medicaid Services. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. Our site receives compensation from many of the offers listed on the site. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application Involuntary sleepiness during activities that require more active attention, such as talking or driving. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. Typically, your deductible applies to essential CPAP equipment, not including optional accessories. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. CPT Only - American Medical Association, https://jcsm.aasm.org/doi/10.5664/jcsm.7230, https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&, http://aasmnet.org/Resources/PracticeParameters/Outofcenter.pdf, http://jcsm.aasm.org/ViewAbstract.aspx?pid=30972, http://pediatrics.aappublications.org/content/130/3/576.full.pdf+html, https://aasm.org/aasm-introduces-new-patient-education-website-sleepeducation-com/, http://jama.ama-assn.org/cgi/reprint/285/22/2936?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=Patient+page%3A++Breathing+problems+during+sleep&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT. OPT devices (e.g., Winx Sleep Therapy System) 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. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). Flemons WW. Coverage | BlueCross BlueShield of South Carolina Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. 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. Sleep disorder: A disruptive pattern of sleep that may include difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep. Effective April 01, 2023. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). The medical records must also document objective findings of compliance information, (i.e. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. Fletcher EC, Stich J, Yang KL. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. endobj is found to be more effective in the sleep lab to be . 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. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. Most machines record your use for you. When you buy through our links, we may earn a commission. Hyde M, O'Driscoll DM, Binette S, et al. Home diagnosis of sleep apnea: a systematic review of the literature. endobj Click the button below to request a free, no-obligation verification. 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). Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Narcolepsy: This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy). 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

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