Collop NA, Tracy SL, Kapur V, et al. MPTAC review. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. 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. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. 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. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. 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). The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Oral cushion for combination oral/nasal mask, replacement only, each. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. References were updated. American Academy of Sleep Medicine. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. % Over-the-counter (OTC) or prefabricated intra-oral appliances to treat OSA are not considered to be appropriate therapy for OSA in any clinical situation and, therefore, are non-covered. The terms of your CPAP machine, insurance coverage depends on your provider. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. 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. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. A position statement regarding MWT was added. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. Medical Policy & Technology Assessment Committee (MPTAC) review. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. Products or services advertised on this page may be offered by an entity that is affiliated with us. Payment will be made for the purchase of the device when Patient Page. 2007; 30(4):519-529. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. 4510 13th Ave. S. E 1. There are a number of optional accessories you can purchase for your CPAP machine. Fargo, N.D., 58121. 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 . 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. Updated the formatting of the Position Statement section. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. References were updated. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Review your policy to learn about the requirements specific to your insurance provider. People with obstructive sleep apnea experience partial or complete closure of the upper airway during sleep, which can lead to snoring, gasping, or even choking. Most insurance plans partially cover the costs of CPAP machines and related equipment. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Replacement of PAP Devices In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. 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. eligible for coverage. 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. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Not all insurance plans work the same way. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. These include: Insurance does not typically cover any products that are considered optional. 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. Another type of sleep disturbance is simply known as apnea or central apnea. This condition, caused by problems in the central nervous system, is unrelated to OSA and is not addressed in this document. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Mysliwiec V, Martin JL, Ulmer CS, et al. 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. 2007; 1:1-8. Front Psychiatry. Types of coverage. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. This condition is associated with frequent awakening and often with daytime sleepiness. 2001; 19(1):173-186. It happens when the muscles in the throat relax and block the air passages to make sure . Sleep Disorders. Littner M, Hirshkowitz M, Kramer M, et al. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. Flemons WW, Littner MR, Rowley JA, et al. Combination oral/nasal mask, used with continuous positive airway pressure device, each. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. 2019; 10:551. PAP devices have directions from the manufacturing company included for cleaning. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. 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. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. BCBS of Kansas City, March 1, 2019 . 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. MPTAC review. 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. Smith MM, McCrae CC, Cheung JJ, et al. Note:See the table below for the usual maximum amount of accessories considered to be medically necessary. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. Standards of Practice Committee, American Academy of Sleep Medicine. Sleep. 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. 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. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. ; Swiss Respiratory Polygraphy Registry. Masks often cost $100 or more, and other equipment ranges between $20 and $100. Medical policy list. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Before making a final decision, please read the Plan's federal brochure (RI 71-005). This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. 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. O'Driscoll DM, Foster AM, Davey MJ, et al. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. 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. Central Sleep Apnea (CSA) is a serious breathing disorder that disrupts the normal breathing pattern during sleep and negatively affects quality of life and overall cardiovascular health. 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. The criterion standard diagnostic test for sleep disorders is a polysomnogram performed in a sleep laboratory.2 A standard polysomnogram includes EEG, submental electromyogram (EMG) and electrooculogram (to detect rapid eye movement [REM] sleep) for sleep staging. 1. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. 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. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. 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. 2007; 137(5-6):97-102. 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. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. 2023 Blue Cross Blue Shield of North Dakota, Please wait while your form is being submitted, Devices Used for the Treatment of Sleep Apnea in Adults, 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. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. Other insurance providers may have different standards. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 2003; 124(4):1543-1579. 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. 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 This means your doctor still needs to conduct a sleep study to give you a diagnosis. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application Upper airway: The area of the upper respiratory system including the nose, mouth and throat. 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. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. Apnea-Hypopnea index (AHI) or Respiratory disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. 2004; 291(16):2013-2016. Be sure to check your insurance policy to determine your specific requirements. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Learn more. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. 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. But don't worry - our team will handle the legwork in getting them to your insurance company. Flemons WW. Watanabe T, Kumano-Go T, Suganuma N, et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. 3 months/90 days. Providers have the opportunity to review . Indications for treatment of obstructive sleep apnea in adults. No. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Pediatrics. Filters, which need to be replaced frequently, run between $5 and $30 each. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Our site does not include the entire universe of available offers. J Clin Sleep Med. Sleep Diag Ther. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 Click the button below to request a free, no-obligation verification. BCBSNC will provide coverage for surgery for obstructive sleep apnea and upper airway resistance syndrome when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. 3 months/90 days. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. 1997; 20(6):423-487. Kapur VK, Auckley DH, Chowdhuri S, et al. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. Guidelines are designed to support the decision-making processes in patient care. 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. 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. You also avoid the insurance requirements of treatment compliance. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). When you buy through our links, we may earn a commission. Sleep. All rights reserved. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. <> Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. % If you are unable to meet these requirements during the first 3 months, you may have to start the process again. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. endobj Nasal Expiratory Positive Airway Pressure (EPAP). Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 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. 2012; 130(3):576-584. Oxygen saturation measures the significance of respiratory events. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. Centers for Medicare and Medicaid Services. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. The exclusion of obstructive sleep apnea (OSA) as the predominant cause of sleep-associated hypoventilation; For BPAP-ST, the ruling out of CPAP as effective therapy if OSA is a component of the sleep-associated hypoventilation; Significant improvement of the sleep-associated hypoventilation with the use of either PAP device on the settings that will be prescribed for initial use at home, while breathing the individual's prescribed FIO2. J Clin Sleep Med, 2018; 14(7):1231-1237. A provider's office can often get an immediate approval when they submit a request online. 1 0 obj MPTAC review. This change was approved at the November 29, 2007 MPTAC meeting. MPTAC review. Hypopnea: Breathing that is more shallow, and/or slower, than normal. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. 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. 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. endobj <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> 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. Chest. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. 2013; 9(2):125-131. Sleep. 2002; 109(4):e69. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. NCD #240.4.1. Available at: Thurnheer R, Bloch KE, Laube I, et al. An American Academy of Sleep Medicine Report. The two main types of sleep apnea are: 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. Monahan KJ, Larkin EK, Rosen CL, et al. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Sleep Med Rev. 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. Breathing Problems during Sleep. Kryger MH. Standards of Practice Committee of the American Sleep Disorders Association. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Most other equipment ranges between $20 and $100. When services are Investigational and Not Medically Necessary: Unlisted otorhinolaryngological service or procedure [when specified as acoustic pharyngometry] (Note: CPT code 92520 Laryngeal function studies; aerodynamic testing and acoustic testing is not considered appropriate for this service), Actigraphy testing, recording, analysis, interpretation, and report; (minimum of 72 hours to 14 consecutive days of recording), Unlisted neurological or neuromuscular diagnostic procedure [when specified as nap study], Topographic brain mapping [for evaluation of a sleep disorder]. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Dise Is A Prerequisite To Inspire 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). 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.