Your prescription may display an expiration date, in which case it will be valid until this date. 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. Masks often cost $100 or more, and other equipment ranges between $20 and $100. References and Coding sections were also updated. If you're ready for more, sign up to receive our email newsletter! JAMA. x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. Extended! Free CME credits for Training On Bias in Maternal Health Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. More expensive accessories often come with warranties of 1 to 3 years. 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. 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. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. Med Clin North Am. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Fletcher EC, Stich J, Yang KL. This condition is associated with frequent awakening and often with daytime sleepiness. Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Available at: Berry RB, Quan SF, Abreu AR, et al. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. Clinical practice. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. D'Andrea LA. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . Sleep Apnea. 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. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application This is a unique virtual learning experience for health care professionals caring for women and . Recommendations from other national entities may vary. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. 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". In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. 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). Note: CPAP has been shown to have greater effectiveness than oral appliances in general. Your doctor must determine which type of study is right for you. Fargo, N.D., 58121. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. More than 75% of the apneas or hypopneas must have an obstructive pattern. 2007; 1:1-8. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). Clin Chest Med. 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. 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. 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). Can actigraphy measure sleep fragmentation in children? That said, coverage varies depending on your plan, insurance company, and authorization requirements. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The two main types of sleep apnea are: American Academy of Pediatrics (AAP). 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. Inspire Medical wins coverage from five more BCBS plans %PDF-1.7 Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. Medical policy list | Blue Shield of CA Provider Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Sleep Medicine - Regence Narcolepsy: This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy). J Clin Sleep Med. Swiss Med Wkly. When you buy through our links, we may earn a commission. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Pediatr Clin North Am. J Sleep Res. 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). This limits your coverage options, and you may not get the exact product you desire. Updated Coding section with 01/01/2010 CPT changes. stream 2000; 9(2):168-174. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. endobj Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. Watanabe T, Kumano-Go T, Suganuma N, et al. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Required fields are marked *. Available at: Journal of the American Medical Association. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Home diagnosis of sleep apnea: a systematic review of the literature. Efforts are made to maintain reliable data on all information presented. 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 American Academy of Sleep Medicine (AASM). Sleep Disorders. Tubing with integrated heating element for use with positive airway pressure device, Combination oral/nasal mask, used with continuous positive airway pressure device, each, Oral cushion for combination oral/nasal mask, replacement only, each, Nasal pillows for combination oral/nasal mask, replacement only, pair, Full face mask used with positive airway pressure device, each, Face mask interface, replacement for full face mask, each, Cushion for use on nasal mask interface, replacement only, each, Pillow for use on nasal cannula type interface, replacement only, pair, Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap, Headgear used with positive airway pressure device, Chinstrap used with positive airway pressure device, Tubing used with positive airway pressure device, Filter, disposable, used with positive airway pressure device, Filter, non-disposable, used with positive airway pressure device, Oral interface used with positive airway pressure device, each, Exhalation port with or without swivel used with accessories for positive airway pressure devices, replacement only, Water chamber for humidifier, used with positive airway pressure device, replacement, each, **Allowing for a three (3) month supply *Allows for a 10 day delivery before run-out. Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. <> Medically necessary criteria regarding Type III home portable devices were updated with information about newer models of the SNAP devices that are considered Type III devices. Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. Trikalinos TA, Ip S, Raman G, et al. Thanks for the feedback - we're glad you found our work instructive! Your daily habits and environment can significantly impact the quality of your sleep. 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. Chesson AL Jr, Berry RB, Pack A. Most insurance plans partially cover the costs of CPAP machines and related equipment. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. Review your policy to learn about the requirements specific to your insurance provider. 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. 4510 13th Ave. S. Devices Used for the Treatment of Sleep Apnea in Adults 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. New Policy for Obstructive Sleep Apnea (OSA) and Sleep Devices The members contract benefits in effect on the date that services are rendered must be used. These tests vary in the number and nature of sleep parameters that are measured, in order to gain an understanding of the conditions under which sleep disturbances occur. Collop NA, Tracy SL, Kapur V, et al. Respiratory polygraphy in sleep apnea diagnosis. FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance MPTAC review. Beginning November 1, 2020, we have a contracted network of dental providers with American Academy Dental Sleep Medicine (AADSM) certification to supply custom fitted sleep appliances (E0486) that are prescribed by a specialist in sleep disorders and authorized by our Utilization Management department according to the clinical guideline for coverage. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Levenson JC, Troxel WM, Begley A, et al. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. 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. 2002; 347(7):498-504. 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. Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. 3 months/90 days. Your plan may include different types of coverage, such as for health and dental. Then there are supplies that need to be replaced over time, including: The costs for each component vary. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - The reason for this is that CPAP devices are a class II medical device under FDA regulation, meaning you require a prescription in order to obtain one, and in order to get the prescription, you need to undergo a sleep study and have a board-certified sleep specialist physician interpret your results and prescribe CPAP treatment before you undergo CPAP therapy. 2003; 87(4):803-833. Flemons WW, Littner MR, Rowley JA, et al. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. 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. Note: 2001; 19(1):173-186. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. 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). Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. However, youre probably wondering about insurance. 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. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. 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. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. Darien, IL: AASM; 2020. Replacement of PAP Devices American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. Guidelines are designed to support the decision-making processes in patient care. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial Involuntary sleepiness during activities that require more active attention, such as talking or driving. Individuals have failed a prior trial of CPAP. Before making a final decision, please read the Plan's federal brochure (RI 71-005). Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. Government Agency, Medical Society, and Other Authoritative Publications: ActigraphyApnea/Hypopnea Index (AHI)Apnea Risk Evaluation System (ARES)Nap StudyObstructive Sleep Apnea (OSA)Pharyngometry AcousticQuantitative EEG MappingSleepStripSNAP Testing SystemStatic Charge Sensitive BedsTopographic EEG Mapping. 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. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. 2009; 5(3):263-276. 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. Your email address will not be published. The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. The content on this website is for informational purposes only. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. AHRQ Technology Assessment Program. 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 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. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. The use of specific product names is illustrative only. 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. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Polysomnography (PSG) also typically includes electrocardiography and monitoring of 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. 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. Collop NA, Anderson WM, Boehlecke B, et al. 2010; 95(12):1031-1033. 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. PDF Criteria Revised for Diagnosis and Treatment of Obstructive Sleep Apnea for Inspire Medical Systems scores win with Blue Cross Blue Shield
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