He has tested hundreds of mattresses and sleep products. Once the 13 months have passed, you own the machine. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. American Academy of Sleep Medicine (AASM). Liners are not interfaces for use with a PAP mask. More expensive accessories often come with warranties of 1 to 3 years. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. <> No other changes were made to statements or criteria. Flemons WW, Littner MR, Rowley JA, et al. Combination oral/nasal mask, used with continuous positive airway pressure device, each. Neurol Clin. Your coverage which services your plan helps pay for and how the payment structure works depends on the terms of your specific plan. Your daily habits and environment can significantly impact the quality of your sleep. There is no additional payment for liners used with a PAP mask. Sleep. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. Costs for these products can vary depending on the quality. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. 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). O'Driscoll DM, Foster AM, Davey MJ, et al. Airflow and respiratory effort in conjunction with oxygen saturation: These terms are translated into the standard measures of apneic-hypopneic index (AHI) or respiratory disturbance index (RDI). Learn more. Monahan KJ, Larkin EK, Rosen CL, et al. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. Med Clin North Am. Interpretation Obstructive Sleep Apnea (OSA) syndrome consists of a collection of symptoms including daytime sleepiness, fatigue, snoring, and restless sleep with a disrupted sleep pattern. 2008; 162(4):350-358. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 Our site does not include the entire universe of available offers. Your email address will not be published. Med Clin North Am. References and Coding were updated. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 2007; 3(7):737-747. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. MPTAC review. Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. American Academy of Sleep Medicine (AASM) 2007; 1:1-8. Be sure to check your insurance policy to determine your specific requirements. 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). 2017; 13(3):479504. <> 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. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. 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. MPTAC review. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 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. 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. - Comfort Products: Mask Liners, Creams, etc. Our site receives compensation from many of the offers listed on the site. These coverage types are separate from one another. . Review your policy to learn about the requirements specific to your insurance provider. A clarification was made within the Definitions section regarding severe OSA as being defined as an RDI/AHI of greater than 30 (not 40). Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. The Rationale, Definitions and References have been updated. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Netzer NC, Stoohs RA, Netzer CM, et al. Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. 1996; 11(2). 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 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. Fletcher EC, Stich J, Yang KL. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) Sleep. is found to be more effective in the sleep lab to be . <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> Most CPAP machines cost between $500 and $800. Act now to earn free CME credits and helps advance maternal health in New Jersey. Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; The individual is experiencing success in treatment. Other insurance providers may have different standards. AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual or greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention). Available at: Kirk V, Baughn J, D'Andrea L, et al. Save my name, email, and website in this browser for the next time I comment. for the American Academy of Sleep Medicine. 2004; 291(16):2013-2016. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . Oct 1, 2020 Administrative. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from 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. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. 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. Sleep Med Rev. While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis. Swiss Med Wkly. Therefore, it is particularly important that individuals with severe OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance. Littner M, Hirshkowitz M, Kramer M, et al. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. According to the <> Note:See the table below for the usual maximum amount of accessories considered to be medically necessary. 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. References were updated. Measurements usually involve the detection of wrist movements. Blue Cross and Blue Shield Assoc. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. 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. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: Types of coverage. 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. The effective date is February 26, 2018. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. 2000; 9(2):168-174. MPTAC review. Only 10% allow for more frequent replacement. 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. Liners are not interfaces for use with a PAP mask. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. 2019; 46:151-160. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Tubing with integrated heating element for use with positive airway pressure device. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. It happens when the muscles in the throat relax and block the air passages to make sure . Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. This revised Medical Policy will apply to both professional provider and facility claims. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. 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 individuals physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. In order to give you a prescription for a CPAP machine, your doctor must confirm that your sleep difficulties are caused by sleep apnea and not by another condition. A7028. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. 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). Insurance plans can significantly help defray the cost of a CPAP machine. Kryger MH. A position statement regarding MWT was added. Silber MH. Townsend D, Sharma A, Brauer E, et al. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. An American Academy of Sleep Medicine Report. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. 2003; 124(4):1543-1579. Practice Parameters for the Indications for Polysomnography and Related Procedures. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Medical Policy & Technology Assessment Committee (MPTAC) review. 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. Required fields are marked *. 2003; 87(4):803-833. endobj J Clin Sleep Med. (such as sleep studies, CT scans) . 2004; 130(1):58-66. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. 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. MPTAC review. The reason for this is that CPAP devices are a class II medical device under FDA regulation, meaning you require a prescription in order to obtain one, and in order to get the prescription, you need to undergo a sleep study and have a board-certified sleep specialist physician interpret your results and prescribe CPAP treatment before you undergo CPAP therapy. The members contract benefits in effect on the date that services are rendered must be used. endobj 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. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. 2007; 30(4):519-529. 2007; 16(2):213-216. Available at: Morgenthaler T, Alessi C, Friedman L, et al. Kapur VK, Auckley DH, Chowdhuri S, et al. ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - 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. American Academy of Sleep Medicine. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. 1. 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. Mysliwiec V, Martin JL, Ulmer CS, et al. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." BCBS of Kansas City, March 1, 2019 . If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. Effective April 01, 2023. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. 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. Arch Dis Child. Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. The Definitions and References were updated. Your prescription may display an expiration date, in which case it will be valid until this date. Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. 2003; 26(6):754-760. These are not considered interfaces as defined in this policy. Smith MM, McCrae CC, Cheung JJ, et al. <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> Involuntary sleepiness during activities that require more active attention, such as talking or driving. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. 2012; 130(3):576-584. Benefits Application This medical policy relates only to the services or supplies described herein. Guidelines are designed to support the decision-making processes in patient care. 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 equipmentandmeetALLof the following criteria: Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA whenALLof the following criteria are met: 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. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. 2 0 obj Clin Chest Med. Collop NA, Anderson WM, Boehlecke B, et al. Sleep Diag Ther. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Easy Breathe is one of the only online CPAP providers able to bill insurance. 2009; 5(3):263-276. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. minimally invasive solutions for patients with obstructive sleep apnea, announced today that three new Blue Cross Blue Shield Association ("BCBSA") healthcare plans have issued positive coverage policies of Inspire therapy. Masks often cost $100 or more, and other equipment ranges between $20 and $100. Most insurance plans partially cover the costs of CPAP machines and related equipment. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. 2010; 95(12):1031-1033. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. 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. Efforts are made to maintain reliable data on all information presented. 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