blue cross blue shield sleep apnea coverage
Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. 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. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). 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 . These are not considered 'interfaces' as defined in this policy. Medical policy list. 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. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. actigraphy, including use of static charge sensitive beds; diagnostic audio recording, with or without pulse oximetry to document sleep apnea; Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea; Actigraphy or static charge sensitive beds. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. If the criteria are not met, the accessories are considered not medically necessary. Marcus CL, Brooks LJ, Draper KA, et al. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. 1996; 11(2). If youre diagnosed with sleep apnea and require CPAP therapy, its likely your insurance will cover the cost of the device, and the replacements required thereafter. The Rationale, Definitions and Reference sections have also been updated. NCD #240.4.1. If you fail to meet these requirements, you have to begin the process again. Only 10% allow for more frequent replacement. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Products or services advertised on this page may be offered by an entity that is affiliated with us. 1997; 20(6):406-422. Again, this will depend on your individual insurance plan and provider, but in the case of Anthem they offer the following replacement schedule: Generally speaking, most insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. <> 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. MPTAC review. Sleep. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> J Clin Sleep Med. Most machines record your use for you. Levenson JC, Troxel WM, Begley A, et al. When you buy through our links, we may earn a commission. 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. In order to give you a prescription for a CPAP machine, your doctor must confirm that your sleep difficulties are caused by sleep apnea and not by another condition. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. 4510 13th Ave. S. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. 2004; 8(3):611-630. Involuntary sleepiness during activities that require more active attention, such as talking or driving. Your email address will not be published. This is a unique virtual learning experience for health care professionals caring for women and . Your coverage which services your plan helps pay for and how the payment structure works depends on the terms of your specific plan. Inspire Medical Systems - creator of a pacemaker-like system to treat obstructive sleep apnea - said today that the Blue Cross Blue Shield Association's Evidence Street issued a positive . The criteria for home portable monitors/sleep testing have been removed from this document and placed in CG-MED-01 Polysomnography and Home Portable Monitors. 2007; 3(7):737-747. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application First, your doctor must diagnose you with obstructive sleep apnea following an approved laboratory sleep study or an at-home sleep study, and give you a prescription for a CPAP machine. 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. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. Sleep. Version 2.6. American Academy of Sleep Medicine. The Eccovision Acoustic Reflection Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. Coding section was updated. An American Academy of Sleep Medicine Report. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. 1 0 obj 2003, 24(2):307-313. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. This limits your coverage options, and you may not get the exact product you desire. The potential benefits of diagnostic audio recording, used alone or in conjunction with pulse oximetry, have not been demonstrated to provide clinical benefits equivalent to PSG. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. BCBS of Kansas City, March 1, 2019 . Silber MH. MPTAC review. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. The content on this website is for informational purposes only. Information on this website should not be construed as medical advice. Chest. This means your doctor still needs to conduct a sleep study to give you a diagnosis. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. The two main types of sleep apnea are: An independent member of the Blue Shield Association 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome Original Policy Date: April 3, 2009 Effective Date: October 1, 2022 Section: 2.0 Medicine Page: Page 1 of 26 . J Clin Sleep Med. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. JAMA. % 2000; 9(2):168-174. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. 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. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . 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. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. Continued use beyond the first three (3) months of therapy In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. 2004; 130(1):58-66. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. 2009; 5(3):263-276. 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). 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. MPTAC review. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. 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 Diag Ther. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. MPTAC review. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. Your plan may include different types of coverage, such as for health and dental. 2003; 26(6):754-760. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. There is no additional payment for liners used with a PAP mask. <> Kryger MH. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. References and Coding were updated. Conley S, Knies A, Batten J, et al. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. Available at: Berry RB, Quan SF, Abreu AR, et al. Insurance plans can significantly help defray the cost of a CPAP machine. The medical records must also document objective findings of compliance information, (i.e. The terms of your CPAP machine, insurance coverage depends on your provider. Individuals have failed a prior trial of CPAP. 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. This change was approved at the November 29, 2007 MPTAC meeting. 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 If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Swiss Med Wkly. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. This revised Medical Policy will apply to both professional provider and facility claims. 2011; 7(5):531-548. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Clinical practice. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. MPTAC review. Marino M, Li Y, Rueschman MN, et al. Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. 2001; 285(22):2936. 1. Your AHI must also meet the same requirements as for Medicare: If you meet these requirements, then Medicaid provides CPAP coverage for a 12-week trial. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Well cover some of the most common insurance policies surrounding CPAP equipment. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. 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). The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. July 15, 2018. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. 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. MPTAC review. Ann Intern Med. However, youre probably wondering about insurance. Otolaryngol Head Neck Surg. MPTAC review. 2002; 165(11):1499-1503. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. 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. Chest. 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. If you're ready for more, sign up to receive our email newsletter! Obstructive sleep apnea (OSA): This is a form of sleep disturbance, which occurs as the result of a physical occlusion of the upper airway during sleep, which interferes with normal breathing. Not all insurance plans work the same way. Home diagnosis of sleep apnea: a systematic review of the literature. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> The machine is returned to the doctor the following morning for data analysis. According to the 2017; 13(10):1199-1203. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. This condition is associated with frequent awakening and often with daytime sleepiness. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. The use of specific product names is illustrative only. Centers for Medicare and Medicaid Services. 1. Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. References were updated. American Academy of Sleep Medicine; Standards of Practice Committee. CPAP machine prices start around $250 and can reach $1000 or higher. %PDF-1.7 Please reference the Sleep Disorder Management order entry worksheets before submitting your request. BOTH Monahan KJ, Larkin EK, Rosen CL, et al. 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). 2007; 30(4):519-529. All rights reserved. Apnea: A transient period where breathing ceases. MPTAC review. 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. See the table below for the usual maximum amount of accessories considered to be medically necessary. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. 2007; 1:1-8. An American Sleep Disorders Association Report. Combination oral/nasal mask, used with continuous positive airway pressure device, each. Sleep. 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. Updated the formatting of the Position Statement section. J Clin Sleep Med. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. J Clin Sleep Med, 2018; 14(7):1231-1237. Some rental plans may include the cost of replacement equipment, which is something to bear in mind when comparing the cost of buying outright versus going with insurance. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. This is because many insurance plans follow Medicares issued guidelines on the replacement of supplies.If your insurance coverage covers your CPAP on a rental basis, you may be wondering how long the rental period lasts. 2005; 128(4):2166-2175. 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. 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. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. Trikalinos TA, Ip S, Raman G, et al. 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. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. 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. Costs for purchasing a machine outright can range anywhere from $250 to $1,000 or more, depending on where you live and the type of machine you need. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 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. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. Policy and Coverage Criteria for Commercial Products: . Filters, which need to be replaced frequently, run between $5 and $30 each. People with obstructive sleep apnea experience partial or complete closure of the upper airway during sleep, which can lead to snoring, gasping, or even choking. Arch Fam Med. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Neurol Clin. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. A trial with CPAP has failed or is contraindicated; The device is prescribed by a treating physician; The device is custom-fitted by qualified dental personnel; There is absence of temporomandibular dysfunction or periodontal disease. If your CPAP prescription mentions a Lifetime Need or says 99 months, this means that the prescription is valid for as long as you require the therapy. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Contact Carelon online via Carelon's ProviderPortalor call toll-free at 1 (877) 291-0509, 8 a.m. - 5 p.m. PST Monday through Friday to request an order number. J Clin Sleep Med. Wide deviations in the conditions and data collection methods available cause significant variability in the outcomes of these studies and do not allow for proper sleep assessment. x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). 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 individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device.
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