Our site does not include the entire universe of available offers. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. MPTAC review. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. Updates to Sleep Apnea Corporate Medical Policy - Blue Cross NC Nasal Expiratory Positive Airway Pressure (EPAP). 1. When services are Investigational and Not Medically Necessary: Unlisted otorhinolaryngological service or procedure [when specified as acoustic pharyngometry] (Note: CPT code 92520 Laryngeal function studies; aerodynamic testing and acoustic testing is not considered appropriate for this service), Actigraphy testing, recording, analysis, interpretation, and report; (minimum of 72 hours to 14 consecutive days of recording), Unlisted neurological or neuromuscular diagnostic procedure [when specified as nap study], Topographic brain mapping [for evaluation of a sleep disorder]. PAP devices may improve quality of life in individuals with sleep apnea in adults. Marcus CL, Brooks LJ, Draper KA, et al. 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. 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. 2000; 9(2):168-174. 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. 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. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Removed ICD-9 codes from Coding section. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Individuals have failed a prior trial of CPAP. The Definitions and References were updated. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. 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. State Medicaid programs typically follow the same guidelines as Medicare. Filters, which need to be replaced frequently, run between $5 and $30 each. This condition is associated with frequent awakening and often with daytime sleepiness. 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. 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. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and 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). 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. Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. endobj 2001; 19(1):173-186. 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. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. 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. American Sleep Disorders Association and Sleep Research Society. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. 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. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. J Clin Sleep Med. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. Med Clin North Am. 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. These are not considered 'interfaces' as defined in this policy. Recommendations from other national entities may vary. 2002; 165(11):1499-1503. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). 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. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage 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. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. endobj Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Medical policy list. Available at: Morgenthaler T, Alessi C, Friedman L, et al. 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. Centers for Medicare and Medicaid Services. This means your doctor still needs to conduct a sleep study to give you a diagnosis. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Chest. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. BCBS of Kansas City, March 1, 2019 . Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone (PAT), oximetry and actigraphy may be considered Chesson AL Jr, Ferber RA, Fry JM, et al. The terms of your CPAP machine, insurance coverage depends on your provider. Effective April 01, 2023. Available at. ; Swiss Respiratory Polygraphy Registry. The use of specific product names is illustrative only. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. 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 AHI/RDI greater than 30 is consistent with severe OSA. Mulgrew AT, Fox N, Ayas NT, Ryan CF. 2013; 9(2):125-131. 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. Sleep Medicine - Regence Sleep Disorder Management Program - Horizon Blue Cross Blue Shield of Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . 1997; 20(12):1208. Once the 13 months have passed, you own the machine. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. Smith MM, McCrae CC, Cheung JJ, et al. It isnot intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life (QOL), productivity, and overall health. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. An American Academy of Sleep Medicine Report. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. A7027. Not sure what your Blue Cross insurance covers? Tubing with integrated heating element for use with positive airway pressure device. D'Andrea LA. 3 months/90 days. MPTAC review. Click the button below to request a free, no-obligation verification. The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. PDF FEP Medical Policy Manual Best Anti-Snoring Mouthpieces & Mouthguards, CPAP: Continuous Positive Airway Pressure, Link Between Sleep Apnea and Heart Disease, Medical and Brain Conditions That Cause Excessive Sleepiness, Drowsiness or falling asleep while driving, You have an hourly AHI between 5 and 14 and a, AHI index between 5 and 14, along with a comorbidity related to obstructive sleep apnea; or. 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. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. The following diagnostic tests are considered investigational and not medically necessary: The evidence in the medical literature does not support the use of single nap studies. endobj 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. Kryger MH. Sleep Apnea. Your doctor must determine which type of study is right for you. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. E New Policy for Obstructive Sleep Apnea (OSA) and Sleep Devices Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. 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. 2007; 3(7):737-747. PDF FEP Medical Policy Manual - FEP Blue There are many different types of sleep-related disorders, including obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), insomnia, narcolepsy, nocturnal movement disorders, such as Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD), unexplained excessive daytime sleepiness, and arousal disorders (parasomnias). Breathing Problems during Sleep. American Academy of Sleep Medicine (AASM) Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Respiratory polygraphy in sleep apnea diagnosis. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Continued use beyond the first three (3) months of therapy References and Coding were updated. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. 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.
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