O'Driscoll DM, Foster AM, Davey MJ, et al. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. MPTAC review. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. Go to www.providerportal.com Note: If you've already registered for the ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won't need to register again. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. 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. Providers have the opportunity to review . Standards of Practice Committee of the American Sleep Disorders Association. In order to buy a CPAP machine, you must have results from a sleep study and a CPAP prescription from your doctor or healthcare professional. 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. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. 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 1996; 11(2). It happens when the muscles in the throat relax and block the air passages to make sure . It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). These are not considered 'interfaces' as defined in this policy. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. <> If the criteria are not met, the accessories are considered not medically necessary. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Combination oral/nasal mask, used with continuous positive airway pressure device, each. 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. See the table below for the usual maximum amount of accessories considered to be medically necessary. Sleep. The Rationale, Definitions and Reference sections have also been updated. 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. Available at: Journal of the American Medical Association. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. endobj An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. State Medicaid programs typically follow the same guidelines as Medicare. 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. 1997; 20(6):406-422. 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. 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. 1997; 127(8 Pt 1):581-587. Our site receives compensation from many of the offers listed on the site. Involuntary sleepiness during activities that require more active attention, such as talking or driving. 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 Information on this website should not be construed as medical advice. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Continuous positive airway pressure (CPAP): This is a noninvasive treatment for OSA that involves delivery of pressurized air during sleep through a device that snugly covers the nose. (such as sleep studies, CT scans) . J Clin Sleep Med. Collop NA, Anderson WM, Boehlecke B, et al. American Academy of Sleep Medicine (AASM) The Rationale, Definitions and References were updated. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. 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. 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]. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h Standards of Practice Committee, American Academy of Sleep Medicine. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. 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. 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 . No other changes were made to statements or criteria. 2003; 87(4):803-833. NCD #240.4.1. Mysliwiec V, Martin JL, Ulmer CS, et al. 2019; 46:151-160. That said, coverage varies depending on your plan, insurance company, and authorization requirements. Fletcher EC, Stich J, Yang KL. 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. Available at: Kirk V, Baughn J, D'Andrea L, et al. This means your doctor still needs to conduct a sleep study to give you a diagnosis. This revised Medical Policy will apply to both professional provider and facility claims. Am J Respir Crit Care Med. 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. Sleep. 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). 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. July 15, 2018. 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. Before making a final decision, please read the Plan's federal brochure (RI 71-005). Version 2.6. References were updated. The members contract benefits in effect on the date that services are rendered must be used. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. This condition is associated with frequent awakening and often with daytime sleepiness. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. Oxygen saturation measures the significance of respiratory events. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. 2017; 13(3):479504. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Revisions also made to Coding section for clarification of MWT coding. 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. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- Flemons WW. Olejniczak PW, Fisch BJ. Kryger MH. American Academy of Sleep Medicine (AASM). Treatment of Obstructive Sleep Apnea Procedure code: E0601 Background: Sleep Apnea Sleep apnea occurs when an adult stops breathing or has slowed breathing during sleep. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Marcus CL, Brooks LJ, Draper KA, et al. More than 75% of the apneas or hypopneas must have an obstructive pattern. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. Many Blue Cross PPO type plans have excellent out-of-network coverage, and many of our patients end up paying the same or even less with us than with an in-network provider. Clin Chest Med. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. Practice parameters for using polysomnography to evaluate insomnia: an update. Available at: Berry RB, Quan SF, Abreu AR, et al. J Clin Sleep Med. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Flemons WW, Littner MR, Rowley JA, et al. Kapur VK, Auckley DH, Chowdhuri S, et al. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. 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). The Rationale, Definitions and References have been updated. Practice Parameters for the Indications for Polysomnography and Related Procedures. Apnea: A transient period where breathing ceases. 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. - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. More expensive accessories often come with warranties of 1 to 3 years. The indications for polysomnography and related procedures. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. 2007; 137(5-6):97-102. Diagnosis and management of childhood obstructive sleep apnea syndrome. 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). BCBS of Kansas, which covers approximately 560,000 members.. 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. Masks often cost $100 or more, and other equipment ranges between $20 and $100. Your email address will not be published. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. MPTAC review. 1. 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. The technique is based on the analysis of sound waves that are launched from a loudspeaker and travel along a wave tube into the subjects airways where they are reflected. No. Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. . According to the A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. Filters, which need to be replaced frequently, run between $5 and $30 each. While the use of actigraphy has been demonstrated to be useful in the detection of sleep problems in healthy or normal individuals, potential benefits for individuals with suspected sleep disorders have not been shown. 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. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. A provider's office can often get an immediate approval when they submit a request online. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Marino M, Li Y, Rueschman MN, et al. Please refer to the members contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. MPTAC review. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Oral cushion for combination oral/nasal mask, replacement only, each. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. Shift work sleep disorder (SWSD): A sleep disorder that is related to unusual or constantly changing work schedules and results in symptoms of insomnia or excessive sleepiness. J Clin Sleep Med. Sleep. 2000; 9(2):168-174. The terms of your CPAP machine, insurance coverage depends on your provider. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Not sure what your Blue Cross insurance covers? Indications for treatment of obstructive sleep apnea in adults. Take the Sleep Quiz to help inform your sleep improvement journey. Levenson JC, Troxel WM, Begley A, et al. Blue Cross and Blue Shield Assoc. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. MPTAC review. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. The American Academy of Sleep Medicine (AASM) Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults, updated in 2009, stated: Actigraphy alone is not indicated for the routine diagnosis of obstructive sleep apnea (OSA) but may be a useful adjunct to portable monitors (PMs) when determining the rest-activity pattern during the testing period (Option) (Epstein, 2009). Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. 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 following codes for treatments and procedures applicable to this document are included below for informational purposes. Blue Cross Blue Shield North Carolina does cover weight loss surgery, but your specific policy must include it in order for you get it covered. Interpretation Obstructive Sleep Apnea (OSA) syndrome consists of a collection of symptoms including daytime sleepiness, fatigue, snoring, and restless sleep with a disrupted sleep pattern. 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. Replacement of PAP Devices <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Learn more. Sleep Diag Ther. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Required fields are marked *. Polysomnography (PSG) also typically includes electrocardiography and monitoring of 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. 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. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. 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. Annals Intern Med. Respiratory polygraphy in sleep apnea diagnosis. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. endobj The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 JAMA. Technology Evaluation Center (TEC) assessments. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. 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. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. Other criteria are unchanged for MSLT and other services. Sleep. 4 0 obj Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. This document addresses selected services for the diagnosis of sleep disorders including: Investigational and Not Medically Necessary: Nap studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Efforts are made to maintain reliable data on all information presented. MPTAC review. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. 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). Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. 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. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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 3 0 obj You must also adhere to the same compliance requirements as Medicare recipients, namely using the machine at least 4 hours every night on 70% of nights. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. 2002; 109(4):e69. Click the button below to request a free, no-obligation verification. <> Sleep Disorders. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. Chesson AL Jr, Berry RB, Pack A. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. These include: Insurance does not typically cover any products that are considered optional. 2007; 3(7):737-747. These coverage types are separate from one another. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. 2003, 26(7):907-913. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> 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. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks.
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