Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. Policy and Coverage Criteria for Commercial Products: . 1997; 20(6):423-487. 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. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Along with key review factors, this compensation may impact how and where products appear across the site (including, for example, the order in which they appear). D'Andrea LA. 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. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. 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. 2013; 36(11):1747-1755. 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. 4 0 obj 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. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- Clinical practice. Breathing Problems during Sleep. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. Conley S, Knies A, Batten J, et al. Kapur VK, Auckley DH, Chowdhuri S, et al. Sleep. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and 1 0 obj Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. A7027. PDF 969 Sleep Disorder Management - bluecrossma.org Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. 2003, 26(7):907-913. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. The medical records must also document objective findings of compliance information, (i.e. 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. 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. 2003; 87(4):803-833. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Horizon Blue Cross Blue Shield of New Jersey partnered with the March of Dimes to offer an eLearning session on implicit bias called Awareness to Action: Dismantling Bias in Maternal and Infant Healthcare. Typically, you need a referral for a sleep study in order to receive coverage. 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. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. 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). If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. 2020; 172(5):325-336. Note: Oxygen saturation measures the significance of respiratory events. Not sure what your Blue Cross insurance covers? Upper airway: The area of the upper respiratory system including the nose, mouth and throat. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. An American Sleep Disorders Association Report. Take the Sleep Quiz to help inform your sleep improvement journey. He has tested hundreds of mattresses and sleep products. 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. MPTAC review. Sleep Med Rev. Available at: Berry RB, Quan SF, Abreu AR, et al. Version 2.6. The use of specific product names is illustrative only. Removed ICD-9 codes from Coding section. PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI 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. The content on this website is for informational purposes only. Updates to Sleep Apnea Corporate Medical Policy - Blue Cross NC The effective date is February 26, 2018. An AHI between 5 and 15 is considered mild, an AHI between 15 and 30 is moderate, and an AHI greater than 30 is severe. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. No. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h A7028. 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". . Monahan KJ, Larkin EK, Rosen CL, et al. Medical policy list. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. Guidelines are designed to support the decision-making processes in patient care. 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). 3 months/90 days. Pediatrics. Arch Pediatr Adolesc Med. The Rationale, Definitions and Reference sections have also been updated. Practice Parameters for the Indications for Polysomnography and Related Procedures. N Engl J Med. Littner M, Hirshkowitz M, Kramer M, et al. Other criteria are unchanged for MSLT and other services. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). State of South Carolina - Coverage Information Rationale section was updated with information about acoustic pharyngometry and SNAP testing. 2013; 9(2):125-131. 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. 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. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC Replacement of PAP Devices Please reference the Sleep Disorder Management order entry worksheets before submitting your request. Werner H, Molinari L, Guyer C, Jenni OG. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. ** Medical Management of Obstructive Sleep Apnea Syndrome Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Well cover some of the most common insurance policies surrounding CPAP equipment. - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. References and Coding were updated. 2000; 3(4):169-172. endobj 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). A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Arch Dis Child. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Easy Breathe is one of the only online CPAP providers able to bill insurance. Costs for these products can vary depending on the quality. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. Home diagnosis of sleep apnea: a systematic review of the literature. 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. Trikalinos TA, Ip S, Raman G, et al. If you have any questions about the guidelines, or wish to provide feedback, this can be done by contacting the Quality Improvement Department at 312-653-3465. 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. 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. C. Recent Home Sleep Apnea Test (HSAT) (less than 1 year old) confirmed to be non-diagnostic: Not all insurance plans work the same way. Oral cushion for combination oral/nasal mask, replacement only, each. 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 When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. Easy Breathe is one of the only online CPAP providers able to bill insurance. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. 3 0 obj CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Smith MM, McCrae CC, Cheung JJ, et al. Your email address will not be published. 2017; 13(3):479504. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. In order to be eligible for reimbursement, The Centers for Medicaid and Medicare (CMS) require proof that you are using the CPAP machine at least 4 hours per night, on 70% of nights, in a consecutive 30-day period. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Daytime electrical stimulation (eXciteOSA) of the tongue is considered experimental/investigation and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-review literature. Sleep Disorder Management Program - Horizon Blue Cross Blue Shield of An American Academy of Sleep Medicine Report. Available at. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Hyde M, O'Driscoll DM, Binette S, et al. MPTAC review. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. You also avoid the insurance requirements of treatment compliance. 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. Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; The individual is experiencing success in treatment. These are not considered 'interfaces' as defined in this policy. 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. You might be able to find direct-to-supplier CPAP manufacturers with lower prices than those available through your insurance plan, though be sure to check if these devices are approved by the FDA. Sleep education. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. 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. 2023 Blue Cross Blue Shield of North Dakota, Please wait while your form is being submitted, Devices Used for the Treatment of Sleep Apnea in Adults, 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. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Individuals have failed a prior trial of CPAP. Required fields are marked *. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Sleep. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Some providers reimburse you for the cost of purchasing the machine outright, while others require a rent-to-own plan under which you must use the machine for a set amount of time before it becomes your property. 2010; 95(12):1031-1033. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) Olejniczak PW, Fisch BJ. An AHI/RDI greater than 30 is consistent with severe OSA. PAP devices have directions from the manufacturing company included for cleaning. Chest. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. 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).
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