Blue Cross and Blue Shield Kansas is an independent licensee of the Blue Cross Blue Shield Association Contains Public Information Populations Interventions Comparators Outcomes Individuals: With suspected obstructive sleep apnea Interventions of interest are: Limited channel home sleep apnea testing Comparators of interest are: 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. 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. Everyone's insurance plan is different. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. Extended! Free CME credits for Training On Bias in Maternal Health Your AHI is the average number of partial or complete breathing cessation events you experience per hour. 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. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Darien, IL: AASM; 2020. 3 0 obj Otolaryngol Head Neck Surg. 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). 1997; 20(12):1208. 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. PDF FEP Medical Policy Manual - FEP Blue In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. An American Academy of Sleep Medicine Report. Continued use beyond the first three (3) months of therapy. PDF FEP Medical Policy Manual When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. Fletcher EC, Stich J, Yang KL. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. References were updated. Individuals have failed a prior trial of CPAP. The effective date is February 26, 2018. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. MPTAC review. Littner M, Hirshkowitz M, Kramer M, et al. MPTAC review. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. ; Swiss Respiratory Polygraphy Registry. No other changes were made to statements or criteria. 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. These are not considered 'interfaces' as defined in this policy. BlueCross BlueShield of South Carolina Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Policy effective 05/2022 Effective 05/2022 - 84% BlueCross BlueShield of Vermont Sleep Disorders Diagnosis and Treatment Policy effective 04/01/2022 Effective 04/01/2022 - 69% Blue Cross Blue Shield of Wyoming Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 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. Arch Fam Med. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. 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. 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 . Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . Annals Intern Med. 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). Blue Cross and Blue Shield Assoc. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. 1 0 obj AHRQ Technology Assessment Program. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. This condition is associated with frequent awakening and often with daytime sleepiness. Updated coding: Added CPT code 95806 and 0089T; removed CPT codes 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145, 95806, 95808, 95810, 95811, 99508; removed ICD-9 Procedure codes 76.62, 76.63, 76.64, 76.65, 76.66, 89.17; removed HCPCS codes E0561, E0562, E0601, K0183, K0189, K0268, K0531, K0532, K0533, S8260, D7940, D7944, D7946, D7947, D7948, D7949, D7950, D7950, D7995, D7996, S2080, 0088T. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. Practice parameters for using polysomnography to evaluate insomnia: an update. Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. According to the 1 0 obj Guidelines are designed to support the decision-making processes in patient care. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. BCBS of Kansas City, March 1, 2019 . Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). For general information about AIM Specialty Health, call 1-847-564-8500, Monday through Friday, from 9 a.m. to 6 p.m., Eastern Time (ET). 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. 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. Effective April 01, 2023. 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. J Clin Sleep Med. Pediatr Clin North Am. Available at: Morgenthaler T, Alessi C, Friedman L, et al. Additional appliances should be denied as not medically necessary. 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. A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device. These coverage types are separate from one another. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. BCBSNC will provide coverage for Diagnosis and Medical Management of Sleep Apnea when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. The terms of your CPAP machine, insurance coverage depends on your provider. Coverage continues if your sleep apnea improves with the CPAP treatment. Westchester, IL: American Academy of Sleep Medicine; 2007. Oct 1, 2020 Administrative. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. MPTAC review. 2003, 26(7):907-913. 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. Medical Policy | Blue Cross and Blue Shield of Illinois This change was approved at the November 29, 2007 MPTAC meeting. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline. All rights reserved. Sleep Res Online. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. Either a heated humidifier or a non-heated humidifier is eligible for use with a covered PAP device when prescribed by the treating physician to meet the needs of the individual. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Additionally, nap sleep is not physiologically the same as nighttime sleep and does not adequately reflect the range of sleep phases required for proper diagnosis, therefore, results are not accurate when compared to the current standard of a full polysomnography (PSG). 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 The Rationale, Definitions and Reference sections have also been updated. 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. Your plan may include different types of coverage, such as for health and dental. 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). Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. stream Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. According to theAmerican Academy of Sleep Medicine (AASM)obstructive sleep apnea (OSA) in adults is defined as either: Internal Medical Policy Committee 11-19-2020 Added Professional Statement and statement regarding cleaning devices, Internal Medical Policy Committee 9-21-2021 Coding update- Added new procedure code K1027, effective October 01, 2021. 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. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Your daily habits and environment can significantly impact the quality of your sleep. See the table below for the usual maximum amount of accessories considered to be medically necessary. Morgenthaler TI, Aurora RN, Brown T, et al. Sleep Disorders. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from Sleep Apnea. 2013; 9(2):125-131. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Sleep. . Respicardia Announces Highmark Coverage for the rem Act now to earn free CME credits and helps advance maternal health in New Jersey. - Comfort Products: Mask Liners, Creams, etc. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. A clarification was made within the Definitions section regarding severe OSA as being defined as an RDI/AHI of greater than 30 (not 40). 2021 cpaphackers.com | All rights reserved. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Costs for purchasing a machine outright can range anywhere from $250 to $1,000 or more, depending on where you live and the type of machine you need. 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. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. J Sleep Res. 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. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 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. Tubing with integrated heating element for use with positive airway pressure device. J Clin Sleep Med. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Recommendations from other national entities may vary. Pediatrics. Guilleminault C, Abad VC. endobj 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. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Levenson JC, Troxel WM, Begley A, et al. Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. Costs for these products can vary depending on the quality. Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnea, as long as you meet the following requirements: You must also meet Medicares compliance requirements, which state that you must use the machine at least 4 hours per night, 70% of the time or more, during the first 3 months. Strollo PJ Jr. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. The Rationale, Definitions and References have been updated. % American Academy of Sleep Medicine; Standards of Practice Committee. The members contract benefits in effect on the date that services are rendered must be used. 3 months/90 days. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. Sleep Med Rev. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. J Clin Sleep Med. <> However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Silber MH. Monahan KJ, Larkin EK, Rosen CL, et al. 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. 2005; 128(4):2166-2175. Diagnosis and management of childhood obstructive sleep apnea syndrome. Other insurance providers may have different standards. Available at: Berry RB, Quan SF, Abreu AR, et al. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Conley S, Knies A, Batten J, et al. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. Easy Breathe is one of the only online CPAP providers able to bill insurance. 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. C. Recent Home Sleep Apnea Test (HSAT) (less than 1 year old) confirmed to be non-diagnostic: 1. State Medicaid programs typically follow the same guidelines as Medicare. Available at: Thurnheer R, Bloch KE, Laube I, et al. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. 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). 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. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 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. Information was added to the Rationale section regarding MWT, taken from the 2005 updated guideline on Practice Parameters for Clinical Use of MSLT and MWT from the American Academy of Sleep Medicine. 2 0 obj These are not considered interfaces as defined in this policy. Sleep. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. This revised Medical Policy will apply to both professional provider and facility claims. 2003; 124(4):1543-1579. 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. E 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. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. Click the button below to submit your insurance information to us and get started! Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation 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". for the American Academy of Sleep Medicine. 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. risk of central sleep apnea, (chronic use defined as use of opioids on most days per week for greater than 3 months) Obesity hypoventilation syndrome, defined as pCO 2 greater than 45 mm Hg and pO 2 less than 60 mm Hg on arterial blood gas. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use.
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