blue cross blue shield sleep apnea coverageblue cross blue shield sleep apnea coverage

The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. 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. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Individuals have failed a prior trial of CPAP. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. 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". 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. % Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. More than 75% of the apneas or hypopneas must have an obstructive pattern. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Available at: Kirk V, Baughn J, D'Andrea L, et al. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. ; Swiss Respiratory Polygraphy Registry. . Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Inspire Medical wins coverage from five more BCBS plans However, if the member is found to be using the PAP device as directed and is achieving the desired results, the DME supplier must contact the individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. How Often Does Insurance Cover a New CPAP Machine? Arch Fam Med. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. 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). Be sure to check your insurance policy to determine your specific requirements. 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. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. Payment may be made for one (1) appliance. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 Front Psychiatry. Sleep. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. Your plan may include different types of coverage, such as for health and dental. Practice parameters for using polysomnography to evaluate insomnia: an update. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. New Policy for Obstructive Sleep Apnea (OSA) and Sleep Devices Coverage continues if your sleep apnea improves with the CPAP treatment. Pediatrics. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 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. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. The medical records must also document objective findings of compliance information, (i.e. ** Medical Management of Obstructive Sleep Apnea Syndrome The two main types of sleep apnea are: State Medicaid programs typically follow the same guidelines as Medicare. Payment will be made for the purchase of the device when PDF Criteria Revised for Diagnosis and Treatment of Obstructive Sleep Apnea for This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. Updated Coding section with 01/01/2010 CPT changes. Before making a final decision, please read the Plan's federal brochure (RI 71-005). PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL 3 months/90 days. 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. J Clin Sleep Med. J Clin Sleep Med. Oxygen saturation measures the significance of respiratory events. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Respiratory polygraphy in sleep apnea diagnosis. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. 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. stream When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. 2004; 291(16):2013-2016. 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. Neurol Clin. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Once the 13 months have passed, you own the machine. References were updated. J Clin Sleep Med. 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. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. 1 0 obj <> 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). Marino M, Li Y, Rueschman MN, et al. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. There is additionally a vital hereditary component to the disease. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. Inspire Medical Systems scores win with Blue Cross Blue Shield 4510 13th Ave. S. for the American Academy of Sleep Medicine. Click the button below to request a free, no-obligation verification. Devices Used for the Treatment of Sleep Apnea in Adults 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 It happens when the muscles in the throat relax and block the air passages to make sure . More advanced machines tend to cost more. PDF Blue Cross Blue Shield of Michigan Medical Policy This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. 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. 2003, 24(2):307-313. Hypopnea: Breathing that is more shallow, and/or slower, than normal. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. - Power Supplies: CPAP Power Cords and Batteries. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. Netzer NC, Stoohs RA, Netzer CM, et al. Kryger MH. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. 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. CPAP machine prices start around $250 and can reach $1000 or higher. Sleep Med Rev. Close follow-up for PAP device usage and problems in individuals with sleep apnea by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems if needed. Filters, which need to be replaced frequently, run between $5 and $30 each. If you are on a rent-to-own structure, your monthly fee typically equals the cost of the CPAP machine divided by the number of rental months. No. These coverage types are separate from one another. Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. Portable Monitoring Task Force of the American Academy of Sleep Medicine. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Clinical practice. x\Ys~W5p8krxv~qL 4@q_y)N&Bee\>U?0fxywC]|59wo_^UQ^C?^x"/0>_|}yiEQ$5U+/_'~M*yIaaT)GT=r4K%8K^VAfy?WC}l[6~;pklytDRRUAXH,{["GowQmU^VqU0V3,0m0O~d]y Im{W(x9AdWq &KaFgE/ +S/`5UeW'~S#s_jsE;kym+//}1M'x Collop NA, Anderson WM, Boehlecke B, et al. Be aware that if you decide to stop CPAP treatment and decide later that you want to try the treatment again, your insurance company may require you to re-qualify for coverage. A provider's office can often get an immediate approval when they submit a request online. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. Respicardia Announces Highmark Coverage for the rem 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. If you're among the 2% to 9% of adults who suffer from obstructive sleep apnea, a CPAP machine may be the solution to better sleep. 3 0 obj The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. Medical policy list. 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). Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. BOTH endobj The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." MPTAC review. Sleep. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Home diagnosis of sleep apnea: a systematic review of the literature. Policy Statement . 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. An American Sleep Disorders Association Report. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. 2 0 obj Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. These are not considered interfaces as defined in this policy. PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. stream Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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. 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. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. 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. Practice Parameters for the Indications for Polysomnography and Related Procedures. Learn more. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. American Sleep Disorders Association and Sleep Research Society. C. Recent Home Sleep Apnea Test (HSAT) (less than 1 year old) confirmed to be non-diagnostic: 1997; 20(12):1208. 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. 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. Version 2.6. This condition is associated with frequent awakening and often with daytime sleepiness. American Academy of Sleep Medicine; Standards of Practice Committee. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. 2000; 9(2):168-174. 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. endobj Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation References were updated. 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. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: Risk factors for obstructive sleep apnea in adults. % The document header wording was updated from Current Effective Date to Publish Date. References were updated. State of South Carolina - Coverage Information Arch Dis Child. Most insurance plans partially cover the costs of CPAP machines and related equipment. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. Measurements usually involve the detection of wrist movements. Available at: Journal of the American Medical Association. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. 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. 2007; 146(3):157-166. 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. 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. Tubing with integrated heating element for use with positive airway pressure device. Morgenthaler TI, Aurora RN, Brown T, et al. Ann Intern Med. J Clin Sleep Med, 2018; 14(7):1231-1237. Your doctor will first check for symptoms of obstructive sleep apnea, including: If your symptoms indicate you might have obstructive sleep apnea, the next step is to take a sleep study. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. E 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. 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. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. According to the American Academy of Sleep Medicine (AASM), updated definitions of OSA severity are provided as follows: Mild OSA: AHI of 5-15, involuntary sleepiness during activities that require little attention, such as watching TV or reading; Moderate OSA: AHI of 15-30, involuntary sleepiness during activities that require some attention, such as meetings or presentations; Severe OSA: AHI of more than 30, involuntary sleepiness during activities that require more active attention, such as talking or driving (AASM, 2008). 2003; 124(4):1543-1579. MPTAC review. Most other equipment ranges between $20 and $100. Medical policy list | Blue Shield of CA Provider 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. 2013; 36(11):1747-1755. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. 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.