Most insurance plans partially cover the costs of CPAP machines and related equipment. Annals Intern Med. Nasal Expiratory Positive Airway Pressure (EPAP). The indications for polysomnography and related procedures. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. 1. 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 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. When you buy through our links, we may earn a commission. These include: Insurance does not typically cover any products that are considered optional. He has tested hundreds of mattresses and sleep products. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. %PDF-1.7 Review your policy to learn about the requirements specific to your insurance provider. Click the button below to request a free, no-obligation verification. In order to buy a CPAP machine, you must have results from a sleep study and a CPAP prescription from your doctor or healthcare professional. Another type of sleep disturbance is simply known as apnea or central apnea. This condition, caused by problems in the central nervous system, is unrelated to OSA and is not addressed in this document. Sleep 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. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. There is no additional payment for liners used with a PAP mask. Once the 13 months have passed, you own the machine. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. An American Academy of Sleep Medicine Report. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. MPTAC review. % 2017; 13(3):479504. J Clin Sleep Med. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h PDF FEP Medical Policy Manual - FEP Blue AASM | Payer Policy Scorecards See the table below for the usual maximum amount of accessories considered to be medically necessary. MPTAC review. According to theAmerican Academy of Sleep Medicine (AASM)obstructive sleep apnea (OSA) in adults is defined as either: Internal Medical Policy Committee 11-19-2020 Added Professional Statement and statement regarding cleaning devices, Internal Medical Policy Committee 9-21-2021 Coding update- Added new procedure code K1027, effective October 01, 2021. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. N Engl J Med. 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome - Blue Shield of Then there are supplies that need to be replaced over time, including: The costs for each component vary. These are not considered interfaces as defined in this policy. Watanabe T, Kumano-Go T, Suganuma N, et al. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. 1996; 11(2). There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. 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. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. The potential benefits of diagnostic audio recording, used alone or in conjunction with pulse oximetry, have not been demonstrated to provide clinical benefits equivalent to PSG. 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 . Sleep Apnea. Medical Management of Obstructive Sleep Apnea Syndrome Policy # 00328 Original Effective Date: 07/27/2012 Current Effective Date: 01/09/2023 2022 Blue Cross and Blue Shield of Louisiana . 2007; 146(3):157-166. Tubing with integrated heating element for use with positive airway pressure device. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Risk factors for obstructive sleep apnea in adults. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. MPTAC review. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. 2020; 172(5):325-336. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. Information on this website should not be construed as medical advice. - Comfort Products: Mask Liners, Creams, etc. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. Internal Medical Policy Committee 11-23-2021 Revised the way the not medically necessary statements were written; added Daytime electrical stimulation (eXciteOSA) of the tongue. 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. Note:See the table below for the usual maximum amount of accessories considered to be medically necessary. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Hyde M, O'Driscoll DM, Binette S, et al. <> 2000; 9(2):168-174. The use of specific product names is illustrative only. Continued use beyond the first three (3) months of therapy 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. 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 or CPAP devices not meeting the criteria as indicated in this policy are considered not medically necessary. A provider's office can often get an immediate approval when they submit a request online. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. 2002; 109(4):e69. 2017; 13(10):1199-1203. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Medical Policy & Technology Assessment Committee (MPTAC) review. Clin Chest 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. 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. 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. ** Medical Management of Obstructive Sleep Apnea Syndrome Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. Sleep. FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. endobj The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. Updated the formatting of the Position Statement section. How Often Does Insurance Cover a New CPAP Machine? 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. Measurements usually involve the detection of wrist movements. % Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. No other changes were made to statements or criteria. Kapur VK, Auckley DH, Chowdhuri S, et al. It happens when the muscles in the throat relax and block the air passages to make sure . 2002; 165(11):1499-1503. Liners are not interfaces for use with a PAP mask. J Clin Sleep Med. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. Contact Carelon online via Carelon's ProviderPortalor call toll-free at 1 (877) 291-0509, 8 a.m. - 5 p.m. PST Monday through Friday to request an order number. 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). J Clin Sleep Med, 2018; 14(7):1231-1237. Sleep Res Online. Required fields are marked *. 2007; 1:1-8. <> Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Subject: Sleep Testing - Florida Blue 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. References were updated. <> 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. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Marcus CL, Brooks LJ, Draper KA, et al. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) MPTAC review. Guilleminault C, Abad VC. Your email address will not be published. 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. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Providers have the opportunity to review . Easy Breathe is one of the only online CPAP providers able to bill insurance. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. 2004; 130(1):58-66. PDF Blue Cross Blue Shield of Michigan Medical Policy 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). Chest. Conley S, Knies A, Batten J, et al. Respiratory polygraphy in sleep apnea diagnosis. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. 2008; 31(1):141-147. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. - Blue Cross and Blue Shield's Federal Employee Program Ann Intern Med. Combination oral/nasal mask, used with continuous positive airway pressure device, each. Portable Monitoring Task Force of the American Academy of Sleep Medicine. 3 months/90 days. MPTAC review. More than 75% of the apneas or hypopneas must have an obstructive pattern. These are not considered 'interfaces' as defined in this policy. Participating provider network for custom fitted oral sleep alliances Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. 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. MPTAC review. Ann Intern Med. 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. The Rationale, Definitions and References have been updated. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Filters, which need to be replaced frequently, run between $5 and $30 each. 2007; 16(2):213-216. More expensive accessories often come with warranties of 1 to 3 years. CPAP machine prices start around $250 and can reach $1000 or higher. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. The Eccovision Acoustic Reflection Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. E The application of each Blue Shield of California medical policy is subject to regulatory requirements and/or plan specific benefits and limitations (Evidence of Coverage - EOC). Medical policy list | Blue Shield of CA Provider This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. You also avoid the insurance requirements of treatment compliance. The Definitions and References were updated. That said, coverage varies depending on your plan, insurance company, and authorization requirements. Oct 1, 2020 Administrative. Recommendations from other national entities may vary. Darien, IL: AASM; 2020. According to the State of South Carolina - Coverage Information In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. %PDF-1.7 Other insurance providers may have different standards. No. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. MPTAC review. Revisions also made to Coding section for clarification of MWT coding. 2003, 26(7):907-913. You must also adhere to the same compliance requirements as Medicare recipients, namely using the machine at least 4 hours every night on 70% of nights. Morgenthaler TI, Aurora RN, Brown T, et al. Central Sleep Apnea (CSA) is a serious breathing disorder that disrupts the normal breathing pattern during sleep and negatively affects quality of life and overall cardiovascular health. Nap study: This term refers to a shorter daytime version of a PSG sleep study. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. is found to be more effective in the sleep lab to be . Yes! 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. 1 0 obj 1997; 20(6):406-422. 2003, 24(2):307-313. BiPAP without back-up rate may be considered medically necessary for the treatment of OSA in adults and may be considered as durable medical equipment when the following criteria are met: BiPAP without back-up rate devices not meeting the criteria as indicated in this policy are considered not medically necessary. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 2005; 128(4):2166-2175. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. MPTAC review. J Clin Sleep Med. 2003; 87(4):803-833. 2004; 51(1):169-186. 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. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. 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. These coverage types are separate from one another. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Sleep Diag Ther. Centers for Medicare and Medicaid Services. 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. 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. Sleep Medicine - Regence 2004; 291(16):2013-2016. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. 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- Indications for treatment of obstructive sleep apnea in adults. Sleep. JAMA. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Technology Evaluation Center (TEC) assessments. If you're ready for more, sign up to receive our email newsletter! MPTAC review. More advanced machines tend to cost more. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. Standards of Practice Committee of the American Sleep Disorders Association. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. Sleep Management - Blue Cross Blue Shield of Massachusetts 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. Swiss Med Wkly. 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. Chest. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. 4 0 obj BCBS of Kansas City, March 1, 2019 . Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. American Academy of Sleep Medicine; Standards of Practice Committee. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . 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. An American Sleep Disorders Association Report. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. PDF FEP Medical Policy Manual NCD #240.4.1. Practice parameters for using polysomnography to evaluate insomnia: an update. 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
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