Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. 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. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Sleep Res Online. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Swiss Med Wkly. An AHI/RDI greater than 30 is consistent with severe OSA. BCBS of Kansas City, March 1, 2019 . Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. 2004; 51(1):169-186. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. - Comfort Products: Mask Liners, Creams, etc. Updated the formatting of the Position Statement section. References and Coding were updated. PDF 969 Sleep Disorder Management - Blue Cross Blue Shield of Massachusetts 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. 3 0 obj Note: CPAP has been shown to have greater effectiveness than oral appliances in general. PAP (positive airway pressure) Machines and Humidifiers, Typically, filter replacements are every 30 days, Typically, tubing replacements are every 3 months, Typically, mask replacements are every 3 months, 3-month rental, 4th-month purchase (many PPO insurances), 10-month rental (most HMO insurance and some PPO insurances), 13-month rental (Medicare and other government insurance). Take the Sleep Quiz to help inform your sleep improvement journey. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. 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. Filters, which need to be replaced frequently, run between $5 and $30 each. A7027. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. BCBS of Kansas, which covers approximately 560,000 members.. 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. These include: Insurance does not typically cover any products that are considered optional. Arch Pediatr Adolesc Med. 3 months/90 days. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC BOTH Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. 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. If you're among the 2% to 9% of adults who suffer from obstructive sleep apnea, a CPAP machine may be the solution to better sleep. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. 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). Sleep apnea is a harmful condition that can have substantial negative impacts on health. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based polysomnogram (PSG) or with a positive home/portable sleep test); Greater than or equal to 15 events per hour of sleep in an asymptomatic individual; Greater than 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). 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. Standards of Practice Committee, American Academy of Sleep Medicine. Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. An American Academy of Sleep Medicine Report. Flemons WW, Littner MR, Rowley JA, et al. 2017; 13(10):1199-1203. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. <> Most CPAP machines cost between $500 and $800. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Oct 1, 2020 Administrative. Products or services advertised on this page may be offered by an entity that is affiliated with us. Arch Fam Med. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Sleep. References were updated. <> compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. 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. 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. There is additionally a vital hereditary component to the disease. Effective March 3, 2009. 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. 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. 2019; 46:151-160. 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. PAP devices have directions from the manufacturing company included for cleaning. 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. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. The terms of your CPAP machine, insurance coverage depends on your provider. State Medicaid programs typically follow the same guidelines as Medicare. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. MPTAC review. These coverage types are separate from one another. J Clin Sleep Med. MPTAC review. 2020; 172(5):325-336. MPTAC review. Click the button below to submit your insurance information to us and get started! The members contract benefits in effect on the date that services are rendered must be used. The following diagnostic tests are considered investigational and not medically necessary: The evidence in the medical literature does not support the use of single nap studies. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. MPTAC review. - Blue Cross and Blue Shield's Federal Employee Program J Clin Sleep Med. Because CPAP machines and their tubing are required daily, theyre subject to significant wear and tear, so you may be wondering how often insurance will cover CPAP supplies. 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. 2008; 162(4):350-358. 2 0 obj This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. Olejniczak PW, Fisch BJ. BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial 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. J Clin Sleep Med. He has tested hundreds of mattresses and sleep products. Your AHI must also meet the same requirements as for Medicare: If you meet these requirements, then Medicaid provides CPAP coverage for a 12-week trial. Arch Dis Child. If you fail to meet these requirements, you have to begin the process again. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. Conley S, Knies A, Batten J, et al. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. Note: If the CPAP therapy helps improve your sleep apnea symptoms during the 12-week period, Medicare continues to cover the cost of your CPAP equipment. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Liners are not interfaces for use with a PAP mask. 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. 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). July 15, 2018. Efforts are made to maintain reliable data on all information presented. 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). 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. Costs for these products can vary depending on the quality. Daytime electrical stimulation (eXciteOSA) of the tongue is considered experimental/investigation and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-review literature. 2003, 24(2):307-313. Updated Coding section with 01/01/2010 CPT changes. 1997; 127(8 Pt 1):581-587. References were updated. Smith MM, McCrae CC, Cheung JJ, et al. Inspire Medical wins more Blue Cross Blue Shield coverage 2013; 36(11):1747-1755. Trikalinos TA, Ip S, Raman G, et al. 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. Flemons WW. Coding section was updated. Measurements usually involve the detection of wrist movements. 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. 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. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Sleep Disorders. N Engl J Med. MPTAC review. <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> MPTAC review. Removed ICD-9 codes from Coding section. No. Sleep. 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. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. 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. American Academy of Sleep Medicine (AASM). Respiratory polygraphy in sleep apnea diagnosis. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. 1996; 11(2). Werner H, Molinari L, Guyer C, Jenni OG. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. MPTAC review. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. Pediatr Clin North Am. However, this information is provided without warranty. 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. The indications for polysomnography and related procedures. Anthems insurance plans will cover CPAP supplies that are deemed a medical necessity for OSA (obstructive sleep apnea), such as: However, the cost of other accessories for your CPAP machine, including things like cleaning devices or wipes, batteries, or duplicate machines such as travel versions, will not be covered. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . Payment will be made for the purchase of the device when So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. MED.00002 Selected Sleep Testing Services - Anthem Iber C, Ancoli-Israel S, Chesson AL, Quan SF. However, the utility of acoustic pharyngometry measurement in the clinical setting of OSA has not been demonstrated, and it remains unclear how this test will impact treatment planning and clinical outcomes. PDF FEP Medical Policy Manual Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Individuals have failed a prior trial of CPAP. PDF Blue Cross Blue Shield of Michigan Medical Policy Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Benefits Application This medical policy relates only to the services or supplies described herein. Practice parameters for using polysomnography to evaluate insomnia: an update. A provider's office can often get an immediate approval when they submit a request online. A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. ; Swiss Respiratory Polygraphy Registry. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. Ann Intern Med. Medical Policy | Blue Cross and Blue Shield of Illinois Otolaryngol Head Neck Surg. No other changes were made to statements or criteria. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. 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. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Available at. Keep in mind that whether or not you use insurance, medical equipment sellers require a CPAP prescription in order for you to purchase the machine and equipment. 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. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. More advanced machines tend to cost more. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. is found to be more effective in the sleep lab to be . Chesson AL Jr, Berry RB, Pack A. Then there are supplies that need to be replaced over time, including: The costs for each component vary. If the criteria are not met, the accessories are considered not medically necessary. It happens when the muscles in the throat relax and block the air passages to make sure . Your coverage which services your plan helps pay for and how the payment structure works depends on the terms of your specific plan. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and Easy Breathe is one of the only online CPAP providers able to bill insurance. 2000; 9(2):168-174. 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.
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