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. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Seen as youll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. Oral cushion for combination oral/nasal mask, replacement only, each. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. J Sleep Res. Efforts are made to maintain reliable data on all information presented. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . Sleep Management - Blue Cross Blue Shield of Massachusetts 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. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. Coverage | BlueCross BlueShield of South Carolina A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. References were updated. A7028. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. Oxygen saturation measures the significance of respiratory events. Diagnosis and management of childhood obstructive sleep apnea syndrome. The medical records must also document objective findings of compliance information, (i.e. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. 2007; 16(2):213-216. Subject: Sleep Testing - Florida Blue Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. Mysliwiec V, Martin JL, Ulmer CS, et al. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 2007; 3(7):737-747. The Definitions and References were updated. 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. The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. Medical Policy & Technology Assessment Committee (MPTAC) review. 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". Portable Monitoring Task Force of the American Academy of Sleep Medicine. Be aware that if you decide to stop CPAP treatment and decide later that you want to try the treatment again, your insurance company may require you to re-qualify for coverage. Click the button below to submit your insurance information to us and get started! An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application 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). SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. Guilleminault C, Abad VC. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 Payment may be made for one (1) appliance. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. No. Our site does not include the entire universe of available offers. AHRQ Technology Assessment Program. Ann Intern Med. 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. 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. 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. BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. PAP devices may improve quality of life in individuals with sleep apnea in adults. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. MPTAC review. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Once the 13 months have passed, you own the machine. 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 Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. J Clin Sleep Med. Conley S, Knies A, Batten J, et al. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. ** Medical Management of Obstructive Sleep Apnea Syndrome Standards of Practice Committee, American Academy of Sleep Medicine. Arch Dis Child. Revisions also made to Coding section for clarification of MWT coding. Trikalinos TA, Ip S, Raman G, et al. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h 2004; 51(1):169-186. Townsend D, Sharma A, Brauer E, et al. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. Continued use beyond the first three (3) months of therapy. Policy Statement . Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. 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. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. 2000; 9(2):168-174. Measurements usually involve the detection of wrist movements. 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. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. BCBSNC will provide coverage for Diagnosis and Medical Management of Sleep Apnea when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. 2003, 24(2):307-313. In order to prove your eligibility for coverage of your CPAP device, Anthem Blue Cross will require documentation such as relevant doctors notes, sleep test results, a prescription, and may include other documents, too. Other insurance providers may have different standards. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Yes! Sleep. Review your policy to learn about the requirements specific to your insurance provider. %PDF-1.7 Respicardia Announces Highmark Coverage for the rem 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. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. 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 . Available at: Epstein LJ, Kristo D, Strollo PJ, et al. 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 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. BCBS of Kansas, which covers approximately 560,000 members.. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. BCN Sleep Management Program (Testing and Treatment with - BCBSM 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. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. MPTAC review. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. Sleep. Want to read more about all our experts in the field? The most common options include: Medicare may cover a 3-month trial of CPAP therapy, and they may cover it longer if your doctor documents in your medical record that you meet certain conditions regarding the use of the device and they claim that the CPAP therapy is helping you. endobj The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) 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. 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. 2 0 obj Act now to earn free CME credits and helps advance maternal health in New Jersey. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP 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. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. This document addresses selected services for the diagnosis of sleep disorders including: Investigational and Not Medically Necessary: Nap studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy. These are not considered interfaces as defined in this policy. Clinical practice. More expensive accessories often come with warranties of 1 to 3 years. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. Effective April 01, 2023. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Most machines record your use for you. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. This change affects all providers that manage sleep-related care for . Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. Learn more. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline. Participating provider network for custom fitted oral sleep alliances Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. Not all insurance plans work the same way. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. The Rationale, Definitions and References were updated. Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage