We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. J Clin Sleep Med. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. 1 0 obj A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. 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. Chesson AL Jr, Berry RB, Pack A. 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. 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. Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. 2 0 obj This is a unique virtual learning experience for health care professionals caring for women and . 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. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Nasal Expiratory Positive Airway Pressure (EPAP). Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. MPTAC review. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Coverage continues if your sleep apnea improves with the CPAP treatment. Best Anti-Snoring Mouthpieces & Mouthguards, CPAP: Continuous Positive Airway Pressure, Link Between Sleep Apnea and Heart Disease, Medical and Brain Conditions That Cause Excessive Sleepiness, Drowsiness or falling asleep while driving, You have an hourly AHI between 5 and 14 and a, AHI index between 5 and 14, along with a comorbidity related to obstructive sleep apnea; or. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. for the American Academy of Sleep Medicine. PDF FEP Medical Policy Manual Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. References were updated. The document header wording was updated from Current Effective Date to Publish Date. References were updated. endobj Hyde M, O'Driscoll DM, Binette S, et al. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. Devices Used for the Treatment of Sleep Apnea in Adults Guidelines are designed to support the decision-making processes in patient care. PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL 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. J Clin Sleep Med. 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. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. PDF Blue Cross Blue Shield of Michigan Medical Policy Participating provider network for custom fitted oral sleep alliances 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). 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. Your daily habits and environment can significantly impact the quality of your sleep. 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. 2008; 31(1):141-147. Thanks for the feedback - we're glad you found our work instructive! Available at: Berry RB, Quan SF, Abreu AR, et al. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. D'Andrea LA. Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. American Academy of Sleep Medicine (AASM) However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. 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. We regularly assess how the content in this article aligns with current scientific literature and expert recommendations in order to provide the most up-to-date research. 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. Yes! 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. 1. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. Positive Airway Pressure (PAP) Supplies - Regence Ann Intern Med. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. 1 0 obj 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. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> stream Not all insurance plans work the same way. Replacement of PAP Devices 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. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. 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. Only 10% allow for more frequent replacement. References were updated. Home/Portable sleep study (may also be known as NightWatch System, AutoSet Recorder, Morpheus System): A diagnostic test proposed for home use which may be self-administered or attended by a technician. Swiss Med Wkly. Involuntary sleepiness during activities that require more active attention, such as talking or driving. MPTAC review. is found to be more effective in the sleep lab to be . 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. Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. 2001; 285(22):2936. 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. BCBS of Kansas, which covers approximately 560,000 members.. See the table below for the usual maximum amount of accessories considered to be medically necessary. Front Psychiatry. 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. 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 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. 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 the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. More advanced machines tend to cost more. 1996; 11(2). Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. Typically, your deductible applies to essential CPAP equipment, not including optional accessories. Subject: Sleep Testing - Florida Blue A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone (PAT), oximetry and actigraphy may be considered Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 2003; 124(4):1543-1579. Young T, Skatrud J, Peppard PE. 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. Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. Practice parameters for using polysomnography to evaluate insomnia: an update. endobj 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 purchase of the device when 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. 4510 13th Ave. S. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. Polysomnography (PSG) also typically includes electrocardiography and monitoring of The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. %PDF-1.7 This condition is associated with frequent awakening and often with daytime sleepiness. - Any additional medical records, such as your sleep study, that your insurance company requests. It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). American Academy of Sleep Medicine; Standards of Practice Committee. 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- Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). Sleep. JAMA. Dise Is A Prerequisite To Inspire A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. Medical policy list. ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. AASM | Payer Policy Scorecards Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Sleep education. 3 months/90 days. Netzer NC, Stoohs RA, Netzer CM, et al. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . 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. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. 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 relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Am J Respir Crit Care Med. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Clin Chest Med. 2007; 146(3):157-166. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. Types of coverage. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Most machines record your use for you. Then there are supplies that need to be replaced over time, including: The costs for each component vary. The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. Before making a final decision, please read the Plan's federal brochure (RI 71-005). 2003, 24(2):307-313. If youve been diagnosed with sleep apnea, its likely that youll need a CPAP mask, as this is considered the best course of treatment for the condition. Insurance plans can significantly help defray the cost of a CPAP machine. 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. 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. Information was added to the Rationale section regarding MWT, taken from the 2005 updated guideline on Practice Parameters for Clinical Use of MSLT and MWT from the American Academy of Sleep Medicine. 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. 1997; 127(8 Pt 1):581-587. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. Chest. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. Continued use beyond the first three (3) months of therapy 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. Excessive daytime sleepiness: This refers to a condition where a person feels very drowsy during the day, even after getting adequate nighttime rest, and has a tendency to fall asleep or requires extra effort to avoid sleeping in inappropriate situations, such as at work or driving. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. Obstructive sleep apnea syndromes. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). Medical Policy & Technology Assessment Committee (MPTAC) review. Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. Sleep Apnea. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. 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 AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Blue Cross Blue Shield North Carolina does cover weight loss surgery, but your specific policy must include it in order for you get it covered. American Academy of Sleep Medicine (AASM). Morgenthaler TI, Aurora RN, Brown T, et al. Payment may be made for one (1) appliance. 2012; 130(3):576-584. Not sure what your Blue Cross insurance covers? 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. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. No other changes were made to statements or criteria. 2003; 26(6):754-760. Benefits Application This medical policy relates only to the services or supplies described herein. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Clinical practice. Your doctor must determine which type of study is right for you. Recommendations from other national entities may vary. Take the Sleep Quiz to help inform your sleep improvement journey. O'Driscoll DM, Foster AM, Davey MJ, et al. <> Sleep. Respicardia Announces Highmark Coverage for the rem Flemons WW. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Medical policy list | Blue Shield of CA Provider Patient Page. Information on this website should not be construed as medical advice. 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. 1997; 20(12):1208. If the criteria are not met, the accessories are considered not medically necessary. An American Academy of Sleep Medicine Report. There are a number of optional accessories you can purchase for your CPAP machine. This change was approved at the November 29, 2007 MPTAC meeting. 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. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. 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. No. Your email address will not be published. However, this information is provided without warranty.