Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. Most machines record your use for you. - Blue Cross and Blue Shield's Federal Employee Program An American Sleep Disorders Association Report. The effective date is February 26, 2018. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. BCBS of Kansas City, March 1, 2019 . So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. 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. BlueCHiP for Medicare and Commercial Intraoral appliances for use in the treatment of documented mild to moderate obstructive sleep apnea are covered under the member's durable medical equipment service. Sleep Apnea. Pediatrics. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. 2008; 162(4):350-358. 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. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome 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. You also avoid the insurance requirements of treatment compliance. 2010; 95(12):1031-1033. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). %PDF-1.7 The Rationale, Definitions and References have been updated. An AHI between 5 and 15 is considered mild, an AHI between 15 and 30 is moderate, and an AHI greater than 30 is severe. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Arch Dis Child. Flemons WW. Required fields are marked *. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. Neurol Clin. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. If you fail to meet these requirements, you have to begin the process again. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Your plan may include different types of coverage, such as for health and dental. 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. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. PDF Blue Cross Blue Shield of Michigan Medical Policy 1 0 obj Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. 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. 1999; 131(7):485-491. 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. <> endobj The indications for polysomnography and related procedures. Typically, you need a referral for a sleep study in order to receive coverage. 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. Our site does not include the entire universe of available offers. Save my name, email, and website in this browser for the next time I comment. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Trikalinos TA, Ip S, Raman G, et al. Payment will be made for the purchase of the device when Polysomnography (PSG) also typically includes electrocardiography and monitoring of SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. MPTAC review. 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. Technology Evaluation Center (TEC) assessments. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Inspire Medical wins more Blue Cross Blue Shield coverage Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. 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. 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. Sleep. Diagnosis and management of childhood obstructive sleep apnea syndrome. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. 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 Oct 1, 2020 Administrative. 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. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. 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. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage 4510 13th Ave. S. 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. Again, this will depend on your individual insurance plan and provider, but in the case of Anthem they offer the following replacement schedule: Generally speaking, most insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. If you're ready for more, sign up to receive our email newsletter! MPTAC review. Available at: Journal of the American Medical Association. Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. 4 0 obj Rationale section was updated with information about acoustic pharyngometry and SNAP testing. A7028. Following are a list of Blue Cross Blue Shield North Carolina plan types and whether they cover bariatric surgery: Weight Loss Surgery for Health Plans Through Your Work 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. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. If the CPAP therapy helps improve your sleep apnea symptoms during the 12-week period, Medicare continues to cover the cost of your CPAP equipment. These include: Insurance does not typically cover any products that are considered optional. This limits your coverage options, and you may not get the exact product you desire. 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. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> 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. Oral cushion for combination oral/nasal mask, replacement only, each. Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . 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 . Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. A provider's office can often get an immediate approval when they submit a request online. actigraphy, including use of static charge sensitive beds; diagnostic audio recording, with or without pulse oximetry to document sleep apnea; Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea; Actigraphy or static charge sensitive beds. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Sleep Disorders. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Guidelines are designed to support the decision-making processes in patient care. 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. 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. Ann Intern Med. 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. Nap study: This term refers to a shorter daytime version of a PSG sleep study. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and 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 Available at. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. No other changes were made to statements or criteria. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. MPTAC review. J Clin Sleep Med. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Indications for treatment of obstructive sleep apnea in adults. Act now to earn free CME credits and helps advance maternal health in New Jersey. 2002; 109(4):e69. <> American Academy of Sleep Medicine (AASM). If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from Recommendations from other national entities may vary. 3 0 obj Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. endobj 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. is found to be more effective in the sleep lab to be . Conley S, Knies A, Batten J, et al. Inspire Medical wins coverage from five more BCBS plans Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. BiPAP without back-up rate may be considered medically necessary for the treatment of OSA in adults and may be considered as durable medical equipment when the following criteria are met: BiPAP without back-up rate devices not meeting the criteria as indicated in this policy are considered not medically necessary. O'Driscoll DM, Foster AM, Davey MJ, 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. 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. Watanabe T, Kumano-Go T, Suganuma N, et al. 1997; 20(12):1208. If the criteria are not met, the accessories are considered not medically necessary. 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. MPTAC review. 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. Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. Available at: Berry RB, Quan SF, Abreu AR, et al. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Thanks for the feedback - we're glad you found our work instructive! Standards of Practice Committee, American Academy of Sleep Medicine. PDF 969 Sleep Disorder Management - Blue Cross Blue Shield of Massachusetts MPTAC review. Once the 13 months have passed, you own the machine. Your email address will not be published. Sleep apnea is a harmful condition that can have substantial negative impacts on health. MPTAC review. 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. Version 2.6. These are not considered interfaces as defined in this policy. 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. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. 2019; 10:551. Respiratory polygraphy in sleep apnea diagnosis. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. Replacement of PAP Devices These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Otolaryngol Head Neck Surg. Government Agency, Medical Society, and Other Authoritative Publications: ActigraphyApnea/Hypopnea Index (AHI)Apnea Risk Evaluation System (ARES)Nap StudyObstructive Sleep Apnea (OSA)Pharyngometry AcousticQuantitative EEG MappingSleepStripSNAP Testing SystemStatic Charge Sensitive BedsTopographic EEG Mapping. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. More advanced machines tend to cost more. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. It happens when the muscles in the throat relax and block the air passages to make sure . Medical policy list | Blue Shield of CA Provider You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether.

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