<>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Medical policy list | Blue Shield of CA Provider There are a number of optional accessories you can purchase for your CPAP machine. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. J Clin Sleep Med. m|(=IPYAcmAa#nhwRz(v^6;Ut4?o+UIv(($HSnG>:~;khOFtUG+'@Gq^B0kT$Ae/a#*lJk=aZdj~\:POhI-y p;6p=E?t:M?h=U,>) ]1r!!pr8lDbDadJJV|p6l-Dq. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. 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. MPTAC review. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. American Academy of Sleep Medicine (AASM) Respicardia Announces Highmark Coverage for the rem American Academy of Sleep Medicine. MPTAC review. You might be able to find direct-to-supplier CPAP manufacturers with lower prices than those available through your insurance plan, though be sure to check if these devices are approved by the FDA. Liners are not interfaces for use with a PAP mask. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Well cover some of the most common insurance policies surrounding CPAP equipment. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Fletcher EC, Stich J, Yang KL. Oral cushion for combination oral/nasal mask, replacement only, each. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. Providers have the opportunity to review . Townsend D, Sharma A, Brauer E, et al. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. There is no additional payment for liners used with a PAP mask. Benefits Application This medical policy relates only to the services or supplies described herein. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. J Clin Sleep Med. Learn more. Everyone's insurance plan is different. NCD #240.4.1. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's 2007; 3(7):737-747. Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. 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. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance MPTAC review. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. 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. MPTAC review. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Can actigraphy measure sleep fragmentation in children? We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. Note:See the table below for the usual maximum amount of accessories considered to be medically necessary. Sleep education. endobj Mysliwiec V, Martin JL, Ulmer CS, et al. 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. Inspire Medical Systems scores win with Blue Cross Blue Shield A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Replacement of PAP Devices Chest. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. 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. Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. Strollo PJ Jr. References and Coding were updated. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. Standards of Practice Committee of the American Sleep Disorders Association. Coverage continues if your sleep apnea improves with the CPAP treatment. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 2001; 285(22):2936. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. Sleep. Click the button below to submit your insurance information to us and get started! Easy Breathe is one of the only online CPAP providers able to bill insurance. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. PDF 969 Sleep Disorder Management - Blue Cross Blue Shield of Massachusetts Sleep. Neurol Clin. 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. Marino M, Li Y, Rueschman MN, et al. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. 1996; 11(2). Products or services advertised on this page may be offered by an entity that is affiliated with us. BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial Required fields are marked *. Clinical Practice Guidelines | Blue Cross and Blue Shield of Illinois Standards of Practice Committee, American Academy of Sleep Medicine. American Academy of Sleep Medicine (AASM). Your prescription may display an expiration date, in which case it will be valid until this date. 2011; 7(5):531-548. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. 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. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- Medical Policy | Blue Cross and Blue Shield of Illinois Additional appliances should be denied as not medically necessary. 2 0 obj 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. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. 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. Ann Intern Med. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe However, youre probably wondering about insurance. Otolaryngol Head Neck Surg. 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. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC 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. stream AASM | Payer Policy Scorecards E Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 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). This means your doctor still needs to conduct a sleep study to give you a diagnosis. Sleep. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage Individuals have failed a prior trial of CPAP. Indications for treatment of obstructive sleep apnea in adults. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Hypertension 2008; 31(1):141-147. 2007; 1:1-8. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. The effective date is February 26, 2018. First, your doctor must diagnose you with obstructive sleep apnea following an approved laboratory sleep study or an at-home sleep study, and give you a prescription for a CPAP machine. Wide deviations in the conditions and data collection methods available cause significant variability in the outcomes of these studies and do not allow for proper sleep assessment. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: in an asymptomatic individual; More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). D'Andrea LA. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. 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 allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Our site receives compensation from many of the offers listed on the site. Some providers reimburse you for the cost of purchasing the machine outright, while others require a rent-to-own plan under which you must use the machine for a set amount of time before it becomes your property. Subject: Sleep Testing - Florida Blue Sleep Diag Ther. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. 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). An AHI/RDI greater than 30 is consistent with severe OSA. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. 2007; 137(5-6):97-102. 2000; 3(4):169-172. 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. References were updated. 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). Sleep. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. 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. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome - Blue Shield of Sleep disorder: A disruptive pattern of sleep that may include difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep. An American Sleep Disorders Association Report. You also avoid the insurance requirements of treatment compliance. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. 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 Home diagnosis of sleep apnea: a systematic review of the literature. <> A trial with CPAP has failed or is contraindicated; The device is prescribed by a treating physician; The device is custom-fitted by qualified dental personnel; There is absence of temporomandibular dysfunction or periodontal disease. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. American Academy of Sleep Medicine (AASM). More expensive accessories often come with warranties of 1 to 3 years. 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. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. The content on this website is for informational purposes only. More than 75% of the apneas or hypopneas must have an obstructive pattern. 2003, 24(2):307-313. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. %PDF-1.7 compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. 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 . When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. Fargo, N.D., 58121. PAP (positive airway pressure) Machines and Humidifiers, Typically, filter replacements are every 30 days, Typically, tubing replacements are every 3 months, Typically, mask replacements are every 3 months, 3-month rental, 4th-month purchase (many PPO insurances), 10-month rental (most HMO insurance and some PPO insurances), 13-month rental (Medicare and other government insurance). PDF FEP Medical Policy Manual References were updated. 2004; 130(1):58-66. Patient Page. Review your policy to learn about the requirements specific to your insurance provider. Coding section was updated. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. 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). Yes! 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). MPTAC review. 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. Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; The individual is experiencing success in treatment. This change was approved at the November 29, 2007 MPTAC meeting. Filters, which need to be replaced frequently, run between $5 and $30 each. Efforts are made to maintain reliable data on all information presented. When you buy through our links, we may earn a commission. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). Inspire Medical wins more Blue Cross Blue Shield coverage Here is what we need in order to verify your insurance coverage: After getting you a quote for your insurance benefits, Easy Breathe will help you contact your doctor's office for the following: These documents are needed in order to show medical necessity to your insurance company. References and Coding sections were also updated. Arch Dis Child. Removed ICD-9 codes from Coding section. 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. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . Available at: Morgenthaler T, Alessi C, Friedman L, et al. PDF 969 Sleep Disorder Management - bluecrossma.org Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. Available at. Some rental plans may include the cost of replacement equipment, which is something to bear in mind when comparing the cost of buying outright versus going with insurance. Liners are not interfaces for use with a PAP mask. 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 and meet ALL of the following criteria: Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA when ALL of the following criteria are met: Intra-oral devices not meeting the criteria as indicated in this policy are considered not medically necessary. This condition is associated with frequent awakening and often with daytime sleepiness. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. Oxygen saturation measures the significance of respiratory events. 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. 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. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. BCBS of Kansas City, March 1, 2019 . 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- Guidelines are designed to support the decision-making processes in patient care. Other insurance providers may have different standards. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI 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". If you require more frequent replacements of certain components, those costs may be out of pocket. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. 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. A provider's office can often get an immediate approval when they submit a request online. According to the Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. New Policy for Obstructive Sleep Apnea (OSA) and Sleep Devices Costs for these products can vary depending on the quality. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Centers for Medicare and Medicaid Services. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. Tubing with integrated heating element for use with positive airway pressure device. Because CPAP machines and their tubing are required daily, theyre subject to significant wear and tear, so you may be wondering how often insurance will cover CPAP supplies. Only 10% allow for more frequent replacement. 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. BCBS of Kansas, which covers approximately 560,000 members.. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. MPTAC review. CPAP machine prices start around $250 and can reach $1000 or higher. Medical policy list. 2002; 165(11):1499-1503. 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. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Continued use beyond the first three (3) months of therapy BOTH 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. Insurance plans can significantly help defray the cost of a CPAP machine. Sleep Disorder Management Program - Horizon Blue Cross Blue Shield of
During The Breathing Task For Infants You Should Quizlet, 225 Bench Press Combine Record, Articles B