blue cross blue shield sleep apnea coverage blue cross blue shield sleep apnea coverage

SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. 2003, 26(7):907-913. endobj Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. On the other hand, if you have a co-insurance plan, you will also be billed monthly for the rental cost of the device, alongside your insurance company. 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. Nasal Expiratory Positive Airway Pressure (EPAP). - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. References were updated. J Clin Sleep Med. More advanced machines tend to cost more. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. 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. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. Your daily habits and environment can significantly impact the quality of your sleep. That said, coverage varies depending on your plan, insurance company, and authorization requirements. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. 2017; 13(3):479504. 2008; 162(4):350-358. The following changes will be effective April 1, 2015, to the Blue Cross and Blue Shield of North Carolina corporate medical policy titled "Sleep Apnea: Diagnosis and Medical Management". Trikalinos TA, Ip S, Raman G, et al. E 2007; 30(4):519-529. Arch Pediatr Adolesc Med. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. for the American Academy of Sleep Medicine. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. J Clin Sleep Med. 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]. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Be sure to check your insurance policy to determine your specific requirements. Swiss Med Wkly. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. . Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 Not sure what your Blue Cross insurance covers? 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. 2 0 obj MPTAC review. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Most other equipment ranges between $20 and $100. The Rationale, Definitions and References have been updated. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. 3 months/90 days. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. 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. 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. MPTAC review. Act now to earn free CME credits and helps advance maternal health in New Jersey. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. 2008; 31(1):141-147. Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. Not all insurance plans work the same way. Involuntary sleepiness during activities that require more active attention, such as talking or driving. Chesson AL Jr, Berry RB, Pack A. 1997; 20(12):1208. 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. Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. MPTAC review. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Sleep education. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. Blue Cross and Blue Shield Assoc. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. 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. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. 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. References and Coding sections were also updated. 2017; 13(10):1199-1203. 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). MPTAC review. Available at: Berry RB, Quan SF, Abreu AR, et al. Collop NA, Anderson WM, Boehlecke B, et al. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 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. 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. 2013; 36(11):1747-1755. Annals Intern Med. Nap study: This term refers to a shorter daytime version of a PSG sleep study. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. Then there are supplies that need to be replaced over time, including: The costs for each component vary. Sleep. ** Medical Management of Obstructive Sleep Apnea Syndrome 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. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 2007; 3(7):737-747. All rights reserved. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. JAMA. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Marcus CL, Brooks LJ, Draper KA, et al. Home diagnosis of sleep apnea: a systematic review of the literature. 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. Monahan KJ, Larkin EK, Rosen CL, et al. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. Click the button below to submit your insurance information to us and get started! Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. Payment may be made for one (1) appliance. 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). Measurements usually involve the detection of wrist movements. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. Medical Policy & Technology Assessment Committee (MPTAC) review. Airflow and respiratory effort in conjunction with oxygen saturation: These terms are translated into the standard measures of apneic-hypopneic index (AHI) or respiratory disturbance index (RDI). SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. Westchester, IL: American Academy of Sleep Medicine; 2007. MPTAC review. The document header wording was updated from Current Effective Date to Publish Date. References were updated. The Rationale, Definitions and Reference sections have also been updated. There are a number of optional accessories you can purchase for your CPAP machine. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. minimally invasive solutions for patients with obstructive sleep apnea, announced today that three new Blue Cross Blue Shield Association ("BCBSA") healthcare plans have issued positive coverage policies of Inspire therapy. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 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 provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. 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. 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). This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. These coverage types are separate from one another. Typically, your deductible applies to essential CPAP equipment, not including optional accessories. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). More than 75% of the apneas or hypopneas must have an obstructive pattern. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. 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. MPTAC review. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. See the table below for the usual maximum amount of accessories considered to be medically necessary. Littner M, Hirshkowitz M, Kramer M, et al. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. Other criteria are unchanged for MSLT and other services. 1996; 11(2). This means your doctor still needs to conduct a sleep study to give you a diagnosis. Chest. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. 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. 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. 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. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. 2021 cpaphackers.com | All rights reserved. Breathing Problems during Sleep. Obstructive sleep apnea. 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. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. 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. References were updated. Your doctor will first check for symptoms of obstructive sleep apnea, including: If your symptoms indicate you might have obstructive sleep apnea, the next step is to take a sleep study. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. 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 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). Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Sleep Diag Ther. An American Sleep Disorders Association Report. Well cover some of the most common insurance policies surrounding CPAP equipment. However, this information is provided without warranty. Oct 1, 2020 Administrative. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." 2011; 7(5):531-548. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. 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). In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. These include: Insurance does not typically cover any products that are considered optional. J Clin Sleep Med. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device.