<> The Rationale, Definitions and References have been updated. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. This difference in efficacy is more pronounced for individuals with severe OSA, as oral appliances have been shown to be less efficacious in individuals with severe OSA than they are in individuals with mild-moderate OSA. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. 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. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. 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. 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 Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. AHRQ Technology Assessment Program. Seen as youll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. NCD #240.4.1. D'Andrea LA. JAMA. Available at: Journal of the American Medical Association. Oral cushion for combination oral/nasal mask, replacement only, each. 2007; 137(5-6):97-102. 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. 2002; 165(11):1499-1503. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. 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. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. 2003, 26(7):907-913. Sleep. Pediatrics. 2020; 172(5):325-336. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Measurements usually involve the detection of wrist movements. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. obstructive sleep apnea (OSA) in adults is defined as either: The AASM classifies mild, moderate and severe OSA as: Internal Medical Policy Committee 3-16-2020 Annual Review-no changes, Internal Medical Policy Committee 11-19-2020, Internal Medical Policy Committee 9-21-2021 Coding update- Click the button below to submit your insurance information to us and get started! The indications for polysomnography and related procedures. If your insurance company determines you are not using the machine frequently enough as per your policy, they may stop covering their portion of the machine rental. 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. However, youre probably wondering about insurance. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. 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. Most CPAP machines cost between $500 and $800. J Clin Sleep Med. The most common options include: Medicare may cover a 3-month trial of CPAP therapy, and they may cover it longer if your doctor documents in your medical record that you meet certain conditions regarding the use of the device and they claim that the CPAP therapy is helping you. 2003, 24(2):307-313. 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. 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. Fletcher EC, Stich J, Yang KL. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 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. %PDF-1.7 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. 4 0 obj - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. Medical policy list. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. References were updated. stream However, the utility of acoustic pharyngometry measurement in the clinical setting of OSA has not been demonstrated, and it remains unclear how this test will impact treatment planning and clinical outcomes. 2003; 26(6):754-760. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. The Rationale, Definitions and Reference sections have also been updated. Most insurance plans partially cover the costs of CPAP machines and related equipment. Fargo, N.D., 58121. 2013; 36(11):1747-1755. Kapur VK, Auckley DH, Chowdhuri S, et al. 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. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. E If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. Littner M, Hirshkowitz M, Kramer M, et al. Obstructive sleep apnea. 1997; 20(6):423-487. 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. 2005; 128(4):2166-2175. Excessive daytime sleepiness: This refers to a condition where a person feels very drowsy during the day, even after getting adequate nighttime rest, and has a tendency to fall asleep or requires extra effort to avoid sleeping in inappropriate situations, such as at work or driving. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. Coverage continues if your sleep apnea improves with the CPAP treatment. Only 10% allow for more frequent replacement. 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. MPTAC review. Annals Intern Med. Recommendations from other national entities may vary. These are not considered interfaces as defined in this policy. 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. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. Collop NA, Anderson WM, Boehlecke B, et al. 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. 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. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. 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. 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. Monahan KJ, Larkin EK, Rosen CL, et al. Once the 13 months have passed, you own the machine. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. Updated the formatting of the Position Statement section. MPTAC review. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). Mysliwiec V, Martin JL, Ulmer CS, et al. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. 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. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. 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. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. First, you must have a prescription for CPAP therapy from your healthcare provider. 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. American Sleep Disorders Association and Sleep Research Society. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. Available at: Thurnheer R, Bloch KE, Laube I, et al. 2004; 291(16):2013-2016. 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 or CPAP devices not meeting the criteria as indicated in this policy are considered not medically necessary. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. 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. ** Medical Management of Obstructive Sleep Apnea Syndrome Your doctor must determine which type of study is right for you. J Clin Sleep Med. Oct 1, 2020 Administrative. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. In order to prove your eligibility for coverage of your CPAP device, Anthem Blue Cross will require documentation such as relevant doctors notes, sleep test results, a prescription, and may include other documents, too. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. All rights reserved. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. Thanks for the feedback - we're glad you found our work instructive! Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Available at: Morgenthaler T, Alessi C, Friedman L, et al. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. Can actigraphy measure sleep fragmentation in children? Westbrook PR, Levendowski DJ, Cvetinovic M, et al. The content on this website is for informational purposes only. These coverage types are separate from one another. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 The medical records must also document objective findings of compliance information, (i.e. 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. Flemons WW. This revised Medical Policy will apply to both professional provider and facility claims. Effective April 01, 2023. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Liners are not interfaces for use with a PAP mask. Your prescription may display an expiration date, in which case it will be valid until this date. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. 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. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 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. Olejniczak PW, Fisch BJ. American Academy of Sleep Medicine (AASM). Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. Sleep education. Trikalinos TA, Ip S, Raman G, et al. 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. 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. Keep in mind that whether or not you use insurance, medical equipment sellers require a CPAP prescription in order for you to purchase the machine and equipment. Policy and Coverage Criteria for Commercial Products: . 2007; 3(7):737-747. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. Other insurance providers may have different standards. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. Obstructive sleep apnea syndromes. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Policy Statement . 2019; 46:151-160. There is additionally a vital hereditary component to the disease. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. Costs for these products can vary depending on the quality. 2 0 obj If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. Darien, IL: AASM; 2020. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. Collop NA, Tracy SL, Kapur V, et al. Blue Cross and Blue Shield Assoc. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. 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. Sleep. 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. Practice parameters for using polysomnography to evaluate insomnia: an update. More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) This is a unique virtual learning experience for health care professionals caring for women and . Sleep. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. 2002; 347(7):498-504. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. Available at: Berry RB, Quan SF, Abreu AR, et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. 1999; 131(7):485-491. Otolaryngol Head Neck Surg. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. Chest. This limits your coverage options, and you may not get the exact product you desire.
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blue cross blue shield sleep apnea coverage