blue cross blue shield sleep apnea coverageblue cross blue shield sleep apnea coverage

Sleep Disorders. <> The appropriate setting for standard CPAP treatment is determined during a titration sleep study. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. 4 0 obj - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. No other changes were made to statements or criteria. Payment may be made for one (1) appliance. The medical records must also document objective findings of compliance information, (i.e. 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. Efforts are made to maintain reliable data on all information presented. 2002; 109(4):e69. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. . MPTAC review. The medical records must also document objective findings of compliance information, (i.e. Extended! Free CME credits for Training On Bias in Maternal Health Updated Coding section with 01/01/2010 CPT changes. Polysomnography (PSG) also typically includes electrocardiography and monitoring of 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). 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. Not all insurance plans work the same way. 1. 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. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Medically necessary criteria regarding Type III home portable devices were updated with information about newer models of the SNAP devices that are considered Type III devices. More expensive accessories often come with warranties of 1 to 3 years. Other insurance providers may have different standards. % PDF 969 Sleep Disorder Management - bluecrossma.org This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. These are not considered 'interfaces' as defined in this policy. 3 0 obj 1997; 20(6):423-487. 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. Sleep. Chest. However, none of these portable tests currently provide diagnostic information that is superior to established Type III home portable monitors (HPM), which monitor and record a minimum of four parameters: respiratory movement/effort, airflow, ECG/heart rate, and oxygen saturation. Netzer NC, Stoohs RA, Netzer CM, et al. endobj The machine attaches to a mask that you wear over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open. 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. American Academy of Pediatrics (AAP). Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. All rights reserved. The application of each Blue Shield of California medical policy is subject to regulatory requirements and/or plan specific benefits and limitations (Evidence of Coverage - EOC). 4510 13th Ave. S. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. Your email address will not be published. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Sleep Management - Blue Cross Blue Shield of Massachusetts CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Blue Cross and Blue Shield Assoc. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Silber MH. PAP devices have directions from the manufacturing company included for cleaning. Easy Breathe is one of the only online CPAP providers able to bill insurance. Be sure to check your insurance policy to determine your specific requirements. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Policy and Coverage Criteria for Commercial Products: . 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 Fletcher EC, Stich J, Yang KL. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. Patient Page. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. Otolaryngol Head Neck Surg. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone (PAT), oximetry and actigraphy may be considered If you're ready for more, sign up to receive our email newsletter! If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Your daily habits and environment can significantly impact the quality of your sleep. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. 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. Nasal Expiratory Positive Airway Pressure (EPAP). Olejniczak PW, Fisch BJ. Clinical practice. Subject: Sleep Testing - Florida Blue Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome Other criteria are unchanged for MSLT and other services. The Rationale, Definitions and References were updated. Act now to earn free CME credits and helps advance maternal health in New Jersey. 2013; 36(11):1747-1755. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. This is because many insurance plans follow Medicares issued guidelines on the replacement of supplies.If your insurance coverage covers your CPAP on a rental basis, you may be wondering how long the rental period lasts. J Clin Sleep Med. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. 2004; 51(1):169-186. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Dont forget to budget the ongoing costs of tubes, filters, and other replacements. The document header wording was updated from Current Effective Date to Publish Date. References were updated. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. 3 months/90 days. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. - Any additional medical records, such as your sleep study, that your insurance company requests. 2002; 165(11):1499-1503. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 Mysliwiec V, Martin JL, Ulmer CS, et al. Policy Statement . Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. 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). Ann Intern Med. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. 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. This revised Medical Policy will apply to both professional provider and facility claims. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Young T, Skatrud J, Peppard PE. 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. 2020; 172(5):325-336. D'Andrea LA. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. A position statement regarding MWT was added. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. 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. Your prescription may display an expiration date, in which case it will be valid until this date. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. CPAP machine prices start around $250 and can reach $1000 or higher. Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. There is additionally a vital hereditary component to the disease. 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. Thanks for the feedback - we're glad you found our work instructive! 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. NCD #240.4.1. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Sleep. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. The effective date is February 26, 2018. Practice Parameters for the Indications for Polysomnography and Related Procedures. 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. FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's 1997; 20(12):1208. MPTAC review. Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. Pediatrics. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. 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. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. The technique is based on the analysis of sound waves that are launched from a loudspeaker and travel along a wave tube into the subjects airways where they are reflected. Collop NA, Tracy SL, Kapur V, et al. Centers for Medicare and Medicaid Services. BCBS of Kansas City, March 1, 2019 . Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Inspire Medical Systems scores win with Blue Cross Blue Shield State Medicaid programs typically follow the same guidelines as Medicare. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. 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. 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. 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. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: Nap study: This term refers to a shorter daytime version of a PSG sleep study. 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. The two main types of sleep apnea are: American Sleep Disorders Association and Sleep Research Society. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. These coverage types are separate from one another. 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. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. American Academy of Sleep Medicine; Standards of Practice Committee. Home diagnosis of sleep apnea: a systematic review of the literature. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Breathing Problems during Sleep. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. 2 0 obj Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Inspire Medical wins more Blue Cross Blue Shield coverage In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. 2002; 347(7):498-504. 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]. MPTAC review. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. 2005; 128(4):2166-2175. 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 . compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. 1996; 11(2). 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. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. The Rationale, Definitions and References have been updated. Sleep Diag Ther. 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. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Westchester, IL: American Academy of Sleep Medicine; 2007. These are not considered interfaces as defined in this policy. 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. - Blue Cross and Blue Shield's Federal Employee Program Sleep Medicine - Regence MPTAC review. The content on this website is for informational purposes only. 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. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Sleep. Before making a final decision, please read the Plan's federal brochure (RI 71-005). Coding section was updated. 2007; 137(5-6):97-102. The following diagnostic tests are considered investigational and not medically necessary: The evidence in the medical literature does not support the use of single nap studies. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. Inspire Medical wins coverage from five more BCBS plans Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. 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. Billing for each individual component is considered unbundling of these supplies. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. 1 0 obj Sleep Med Rev. PAP devices may improve quality of life in individuals with sleep apnea in adults. This means your doctor still needs to conduct a sleep study to give you a diagnosis. Darien, IL: AASM; 2020. 1999; 131(7):485-491. Strollo PJ Jr. Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. 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. 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.