Olejniczak PW, Fisch BJ. stream The following codes for treatments and procedures applicable to this document are included below for informational purposes. - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. 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. Guidelines are designed to support the decision-making processes in patient care. 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 . 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. 1997; 20(6):423-487. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. PDF FEP Medical Policy Manual Types of coverage. Inspire Medical wins more Blue Cross Blue Shield coverage MPTAC review. 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. 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. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. 2020; 172(5):325-336. Diagnosis and management of childhood obstructive sleep apnea syndrome. Sleep Disorders. There are a number of optional accessories you can purchase for your CPAP machine. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's References and Coding sections were also updated. 2000; 9(2):168-174. See the table below for the usual maximum amount of accessories considered to be medically necessary. <> %PDF-1.7 Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. More than 75% of the apneas or hypopneas must have an obstructive pattern. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. endobj While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. <> Available at. Sleep Diag Ther. 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. Medical policy list. MPTAC review. Blue Care Network's medical policy on the diagnosis and management of obstructive sleep apnea includes coverage for home sleep studies for members with symptoms of OSA without other comorbid conditions. Blue Cross and Blue Shield Assoc. Your daily habits and environment can significantly impact the quality of your sleep. These include: Insurance does not typically cover any products that are considered optional. 2009; 5(3):263-276. AHRQ Technology Assessment Program. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. (such as sleep studies, CT scans) . 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). Measurements usually involve the detection of wrist movements. Filters, which need to be replaced frequently, run between $5 and $30 each. Easy Breathe is one of the only online CPAP providers able to bill insurance. 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. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage 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. MPTAC review. 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. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. 4 0 obj Blue Cross Sleep Apnea Coverage - HealthySleepClub.com 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. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. The machine is returned to the doctor the following morning for data analysis. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) 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. 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. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Inspire Medical wins coverage from five more BCBS plans American Academy of Sleep Medicine (AASM). OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Sleep Medicine - Regence <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> References were updated. Participating provider network for custom fitted oral sleep alliances Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Inspire Medical Systems scores win with Blue Cross Blue Shield 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). Note: If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. 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. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. American Academy of Sleep Medicine; Standards of Practice Committee. 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. Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. NCD #240.4.1. Updated Coding section with 01/01/2010 CPT changes. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. 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. - Power Supplies: CPAP Power Cords and Batteries. Available at: Journal of the American Medical Association. 1997; 20(6):406-422. Yes! It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. Apnea-Hypopnea index (AHI) or Respiratory disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Home diagnosis of sleep apnea: a systematic review of the literature. Continued use beyond the first three (3) months of therapy. 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. State of South Carolina - Coverage Information Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. J Clin Sleep Med. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. 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. Narcolepsy: This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy). 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. Billing for each individual component is considered unbundling of these supplies. However, this information is provided without warranty. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. But don't worry - our team will handle the legwork in getting them to your insurance company. Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. 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. Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements. If you're ready for more, sign up to receive our email newsletter! JAMA. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Be sure to check your insurance policy to determine your specific requirements. If you fail to meet these requirements, you have to begin the process again. stream Oxygen saturation measures the significance of respiratory events. Other criteria are unchanged for MSLT and other services. Respicardia Announces Highmark Coverage for the rem Standards of Practice Committee of the American Sleep Disorders Association. J Clin Sleep Med. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. Updated the formatting of the Position Statement section. Westchester, IL: American Academy of Sleep Medicine; 2007. 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. 1997; 20(12):1208. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. Home/Portable sleep study (may also be known as NightWatch System, AutoSet Recorder, Morpheus System): A diagnostic test proposed for home use which may be self-administered or attended by a technician.
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