J Clin Sleep Med. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. 2007; 146(3):157-166. Nap study: This term refers to a shorter daytime version of a PSG sleep study. Chesson AL Jr, Berry RB, Pack A. 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. 2003; 26(6):754-760. American Academy of Pediatrics (AAP). Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> First, you must have a prescription for CPAP therapy from your healthcare provider. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). 2007; 137(5-6):97-102. 2005; 128(4):2166-2175. 4 0 obj Nasal Expiratory Positive Airway Pressure (EPAP). Take the Sleep Quiz to help inform your sleep improvement journey. Effective April 01, 2023. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. 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. Oxygen saturation measures the significance of respiratory events. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. 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. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. The Rationale, Definitions and Reference sections have also been updated. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. American Academy of Sleep Medicine (AASM) Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual or greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention). Westbrook PR, Levendowski DJ, Cvetinovic M, et al. 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. Other insurance providers may have different standards. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. Easy Breathe is one of the only online CPAP providers able to bill insurance. Liners are not interfaces for use with a PAP mask. 2000; 9(2):168-174. 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. Benefits Application This medical policy relates only to the services or supplies described herein. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. Once the 13 months have passed, you own the machine. Pediatrics. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 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. 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. Continued use beyond the first three (3) months of therapy The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Watanabe T, Kumano-Go T, Suganuma N, et al. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Practice parameters for using polysomnography to evaluate insomnia: an update. 1. The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. Can actigraphy measure sleep fragmentation in children? Updated the formatting of the Position Statement section. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Before making a final decision, please read the Plan's federal brochure (RI 71-005). Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Centers for Medicare and Medicaid Services. Individuals have failed a prior trial of CPAP. Sleep. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 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. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Updated Coding section with 01/01/2010 CPT changes. Payment may be made for one (1) appliance. MPTAC review. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. 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. 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 . Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) All rights reserved. References were updated. 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. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). 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. % Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. 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. stream A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. is found to be more effective in the sleep lab to be . 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. 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-1.7 Hypertension Programs and resources to help you prevent and manage hypertension. Blue Cross and Blue Shield Kansas is an independent licensee of the Blue Cross Blue Shield Association Contains Public Information Populations Interventions Comparators Outcomes Individuals: With suspected obstructive sleep apnea Interventions of interest are: Limited channel home sleep apnea testing Comparators of interest are: Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. 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. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." The Rationale, Definitions and References have been updated. Annals Intern Med. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. There are a number of optional accessories you can purchase for your CPAP machine. But don't worry - our team will handle the legwork in getting them to your insurance company. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. 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. Sleep. 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. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. Littner M, Hirshkowitz M, Kramer M, et al. This limits your coverage options, and you may not get the exact product you desire. 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. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. 1 0 obj Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. This is a unique virtual learning experience for health care professionals caring for women and . (such as sleep studies, CT scans) . American Academy of Sleep Medicine (AASM). PAP devices have directions from the manufacturing company included for cleaning. C. Recent Home Sleep Apnea Test (HSAT) (less than 1 year old) confirmed to be non-diagnostic: 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. 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. These are not considered 'interfaces' as defined in this policy. Ann Intern Med. Removed ICD-9 codes from Coding section. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. American Academy of Sleep Medicine (AASM). Available at: Journal of the American Medical Association. 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. 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. Available at: Kirk V, Baughn J, D'Andrea L, et al. J Clin Sleep Med. ; Swiss Respiratory Polygraphy Registry. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. The two main types of sleep apnea are: 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. There is additionally a vital hereditary component to the disease. 2007; 1:1-8. References were updated. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. Available at: Berry RB, Quan SF, Abreu AR, et al. Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. 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. Providers have the opportunity to review . The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). Arch Pediatr Adolesc Med. A liner used in conjunction with a PAP mask is considered a comfort and convenience item and is considered a non-covered item or service. 1997; 127(8 Pt 1):581-587. Billing for each individual component is considered unbundling of these supplies. References and Coding were updated. Polysomnography (PSG) also typically includes electrocardiography and monitoring of 2013; 9(2):125-131. Trikalinos TA, Ip S, Raman G, et al. Apnea: A transient period where breathing ceases. Only 10% allow for more frequent replacement. N Engl J Med. Swiss Med Wkly. 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. O'Driscoll DM, Foster AM, Davey MJ, et al. Our site does not include the entire universe of available offers. An American Academy of Sleep Medicine Report. 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. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. 2020; 172(5):325-336. Dise Is A Prerequisite To Inspire % Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. The application of each Blue Shield of California medical policy is subject to regulatory requirements and/or plan specific benefits and limitations (Evidence of Coverage - EOC). 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. 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. An American Sleep Disorders Association Report. An AHI/RDI greater than 30 is consistent with severe OSA. Easy Breathe is one of the only online CPAP providers able to bill insurance. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. 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. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. If you fail to meet these requirements, you have to begin the process again. Sleep. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: <> Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. ** Medical Management of Obstructive Sleep Apnea Syndrome If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. 2010; 95(12):1031-1033. The content on this website is for informational purposes only. Obstructive sleep apnea. Sleep Diag Ther. 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. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. %PDF-1.7 2007; 30(4):519-529. Our site receives compensation from many of the offers listed on the site. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. 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". Kryger MH. Most CPAP machines cost between $500 and $800. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. 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. 2009; 5(3):263-276. Sleep Res Online. More advanced machines tend to cost more. 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. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. JAMA. 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. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. 2019; 10:551. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. OPT devices (e.g., Winx Sleep Therapy System) 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. Strollo PJ Jr. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Policy and Coverage Criteria for Commercial Products: . Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Most other equipment ranges between $20 and $100. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. 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). 3 0 obj Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. The effective date is February 26, 2018. Flemons WW. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Sleep. J Clin Sleep Med. 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. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Chest. Available at. Revisions also made to Coding section for clarification of MWT coding. 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. Sleep. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. Note: 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. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. 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. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. Available at: Morgenthaler T, Alessi C, Friedman L, et al. m|(=IPYAcmAa#nhwRz(v^6;Ut4?o+UIv(($HSnG>:~;khOFtUG+'@Gq^B0kT$Ae/a#*lJk=aZdj~\:POhI-y p;6p=E?t:M?h=U,>) ]1r!!pr8lDbDadJJV|p6l-Dq. 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. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary.

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