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blue cross blue shield sleep apnea coverage

    blue cross blue shield sleep apnea coverage

    While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. Only 10% allow for more frequent replacement. Replacement of PAP Devices A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Your plan may include different types of coverage, such as for health and dental. BCBS of Kansas, which covers approximately 560,000 members.. 2003; 124(4):1543-1579. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. Wide deviations in the conditions and data collection methods available cause significant variability in the outcomes of these studies and do not allow for proper sleep assessment. Beginning November 1, 2020, we have a contracted network of dental providers with American Academy Dental Sleep Medicine (AADSM) certification to supply custom fitted sleep appliances (E0486) that are prescribed by a specialist in sleep disorders and authorized by our Utilization Management department according to the clinical guideline for coverage. Sleep Apnea. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life (QOL), productivity, and overall health. Townsend D, Sharma A, Brauer E, et al. BCBS of Kansas City, March 1, 2019 . Revisions also made to Coding section for clarification of MWT coding. 2017; 13(10):1199-1203. MPTAC review. Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. That said, coverage varies depending on your plan, insurance company, and authorization requirements. Keep in mind that whether or not you use insurance, medical equipment sellers require a CPAP prescription in order for you to purchase the machine and equipment. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. However, this information is provided without warranty. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. An independent member of the Blue Shield Association 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome Original Policy Date: April 3, 2009 Effective Date: October 1, 2022 Section: 2.0 Medicine Page: Page 1 of 26 . Most other equipment ranges between $20 and $100. 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. Technology Evaluation Center (TEC) assessments. The machine is returned to the doctor the following morning for data analysis. The Rationale, Definitions and Reference sections have also been updated. Available at. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. 2007; 1:1-8. 2002; 109(4):e69. Med Clin North Am. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. Coverage continues if your sleep apnea improves with the CPAP treatment. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Anthems insurance plans will cover CPAP supplies that are deemed a medical necessity for OSA (obstructive sleep apnea), such as: However, the cost of other accessories for your CPAP machine, including things like cleaning devices or wipes, batteries, or duplicate machines such as travel versions, will not be covered. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. 2019; 10:551. Typically, your deductible applies to essential CPAP equipment, not including optional accessories. This limits your coverage options, and you may not get the exact product you desire. In order to be eligible for reimbursement, The Centers for Medicaid and Medicare (CMS) require proof that you are using the CPAP machine at least 4 hours per night, on 70% of nights, in a consecutive 30-day period. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. Med Clin North Am. Kryger MH. 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. CPAP therapy is effective, but it can also be expensive. 3 0 obj After reading and interpreting the results of your sleep study, your doctor may diagnose you with sleep apnea and work with you to develop a treatment plan. Providers have the opportunity to review . compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Morgenthaler TI, Aurora RN, Brown T, et al. J Clin Sleep Med. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. 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. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. According to the Not sure what your Blue Cross insurance covers? stream endobj Levenson JC, Troxel WM, Begley A, et al. Easy Breathe is one of the only online CPAP providers able to bill insurance. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Sleep. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. MPTAC review. <> Effective March 3, 2009. 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. Westchester, IL: American Academy of Sleep Medicine; 2007. These are not considered 'interfaces' as defined in this policy. 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. Olejniczak PW, Fisch BJ. An AHI/RDI greater than 30 is consistent with severe OSA. 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. 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). 2007; 3(7):737-747. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. 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. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 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. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. 2000; 9(2):168-174. Strollo PJ Jr. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline. Go to www.providerportal.com Note: If you've already registered for the ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won't need to register again. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. 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. There is no additional payment for liners used with a PAP mask. 2021 cpaphackers.com | All rights reserved. JAMA. More advanced machines tend to cost more. 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. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. Thanks for the feedback - we're glad you found our work instructive! Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. The two main types of sleep apnea are: This is a unique virtual learning experience for health care professionals caring for women and . Be aware that if you decide to stop CPAP treatment and decide later that you want to try the treatment again, your insurance company may require you to re-qualify for coverage. 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 The Definitions and References were updated. 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. Standards of Practice Committee, American Academy of Sleep Medicine. Clinical practice. If you have any questions about the guidelines, or wish to provide feedback, this can be done by contacting the Quality Improvement Department at 312-653-3465. 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 The medical records must also document objective findings of compliance information, (i.e. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Neurol Clin. 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. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. Swiss Med Wkly. Your AHI must also meet the same requirements as for Medicare: If you meet these requirements, then Medicaid provides CPAP coverage for a 12-week trial. Policy and Coverage Criteria for Commercial Products: . endobj Our site receives compensation from many of the offers listed on the site. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. Medical policy list. American Academy of Sleep Medicine. Fargo, N.D., 58121. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. 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. Patient Page. 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. If you require more frequent replacements of certain components, those costs may be out of pocket. More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). 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. 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. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Costs for these products can vary depending on the quality. These tests vary in the number and nature of sleep parameters that are measured, in order to gain an understanding of the conditions under which sleep disturbances occur. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Available at: Kirk V, Baughn J, D'Andrea L, et al. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . 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. 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 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. Efforts are made to maintain reliable data on all information presented. 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. 2019; 46:151-160. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Yes! endobj (such as sleep studies, CT scans) . 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. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements. This revised Medical Policy will apply to both professional provider and facility claims. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. 2012; 130(3):576-584. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. N Engl J Med. In order to buy a CPAP machine, you must have results from a sleep study and a CPAP prescription from your doctor or healthcare professional. The Eccovision Acoustic Reflection Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. 2004; 291(16):2013-2016. Nap study: This term refers to a shorter daytime version of a PSG sleep study. Sleep. 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. Oxygen saturation measures the significance of respiratory events. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. Click the button below to request a free, no-obligation verification. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. The Rationale, Definitions and References were updated. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. 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). Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. Darien, IL: AASM; 2020. - Comfort Products: Mask Liners, Creams, etc. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. - Any additional medical records, such as your sleep study, that your insurance company requests. Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. MPTAC review. 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. Then there are supplies that need to be replaced over time, including: The costs for each component vary. Sleep. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Payment will be made for the purchase of the device when Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. 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. 2017; 13(3):479504. 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. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. 2004; 8(3):611-630. 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). Annals Intern Med. 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. Filters, which need to be replaced frequently, run between $5 and $30 each. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. 3 0 obj criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. 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. 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. 2 0 obj Clin Chest Med. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. MPTAC review. Mysliwiec V, Martin JL, Ulmer CS, et al. 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. There is additionally a vital hereditary component to the disease. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. The medical records must also document objective findings of compliance information, (i.e. Sleep Disorders. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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. <> Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management:

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