Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. MPTAC review. Subject: Sleep Testing - Florida Blue PDF FEP Medical Policy Manual - FEP Blue 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. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. JAMA. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application JAMA. Available at: Kirk V, Baughn J, D'Andrea L, et al. <>
Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Payment will be made for the purchase of the device when 2013; 36(11):1747-1755. 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. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. 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. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. 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. obstructive sleep apnea (OSA) in adults is defined as either: The AASM classifies mild, moderate and severe OSA as: Internal Medical Policy Committee 3-16-2020 Annual Review-no changes, Internal Medical Policy Committee 11-19-2020, Internal Medical Policy Committee 9-21-2021 Coding update- Marino M, Li Y, Rueschman MN, et al. Easy Breathe is one of the only online CPAP providers able to bill insurance. MPTAC review. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Tubing with integrated heating element for use with positive airway pressure device, Combination oral/nasal mask, used with continuous positive airway pressure device, each, Oral cushion for combination oral/nasal mask, replacement only, each, Nasal pillows for combination oral/nasal mask, replacement only, pair, Full face mask used with positive airway pressure device, each, Face mask interface, replacement for full face mask, each, Cushion for use on nasal mask interface, replacement only, each, Pillow for use on nasal cannula type interface, replacement only, pair, Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap, Headgear used with positive airway pressure device, Chinstrap used with positive airway pressure device, Tubing used with positive airway pressure device, Filter, disposable, used with positive airway pressure device, Filter, non-disposable, used with positive airway pressure device, Oral interface used with positive airway pressure device, each, Exhalation port with or without swivel used with accessories for positive airway pressure devices, replacement only, Water chamber for humidifier, used with positive airway pressure device, replacement, each, **Allowing for a three (3) month supply *Allows for a 10 day delivery before run-out. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. Sleep. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. 2013; 9(2):125-131. 1997; 20(6):406-422. 2 0 obj
J Clin Sleep Med. Can actigraphy measure sleep fragmentation in children? Nasal Expiratory Positive Airway Pressure (EPAP). 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. Providers have the opportunity to review . Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. Your doctor must determine which type of study is right for you. Indications for treatment of obstructive sleep apnea in adults. References were updated. Coding section was updated. 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). Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation 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. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. BCBS of Kansas City, March 1, 2019 . Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. Sleep Disorders. 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. Blue Cross and Blue Shield Assoc. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. Neurol Clin. An American Academy of Sleep Medicine Report. Morgenthaler TI, Aurora RN, Brown T, et al. 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. 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. The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. Respicardia Announces Highmark Coverage for the rem AHRQ Technology Assessment Program. endobj
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Strollo PJ Jr. 2021 cpaphackers.com | All rights reserved. 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 medical records must also document objective findings of compliance information, (i.e. 1. 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. Diagnosis and management of childhood obstructive sleep apnea syndrome. 2007; 3(7):737-747. The Definitions and References were updated. E The use of specific product names is illustrative only. 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. Ann Intern Med. Involuntary sleepiness during activities that require more active attention, such as talking or driving. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Our site does not include the entire universe of available offers. Available at: Berry RB, Quan SF, Abreu AR, et al. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. Technology Evaluation Center (TEC) assessments. <>
CPAP therapy is effective, but it can also be expensive. Version 2.6. 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. 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. 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. American Academy of Pediatrics (AAP). Standards of Practice Committee, American Academy of Sleep Medicine. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. 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. The Rationale, Definitions and References have been updated. 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). %
This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. Med Clin North Am. Sleep. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. References were updated. Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. Kryger MH. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. PDF Blue Cross Blue Shield of Michigan Medical Policy Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and If you fail to meet these requirements, you have to begin the process again. endobj
This difference in efficacy is more pronounced for individuals with severe OSA, as oral appliances have been shown to be less efficacious in individuals with severe OSA than they are in individuals with mild-moderate OSA. SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. If you're ready for more, sign up to receive our email newsletter! The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Sleep. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Coverage continues if your sleep apnea improves with the CPAP treatment. 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. endobj
Costs for these products can vary depending on the quality. 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 and meet ALL of the following criteria: Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA when ALL of the following criteria are met: Intra-oral devices not meeting the criteria as indicated in this policy are considered not medically necessary. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Everyone's insurance plan is different. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. Inspire Medical wins coverage from five more BCBS plans Positive Airway Pressure (PAP) Supplies - Regence 2007; 146(3):157-166. Typically, you need a referral for a sleep study in order to receive coverage. Medical Policy & Technology Assessment Committee (MPTAC) review. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Contact Carelon online via Carelon's ProviderPortalor call toll-free at 1 (877) 291-0509, 8 a.m. - 5 p.m. PST Monday through Friday to request an order number. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. 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.
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