More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. JAMA. 1997; 20(6):423-487. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions.
Inspire Medical wins more Blue Cross Blue Shield coverage 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". In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. stream
If the criteria are not met, the accessories are considered not medically necessary. for the American Academy of Sleep Medicine. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. A7028. 2013; 36(11):1747-1755. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. 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]. The document header wording was updated from Current Effective Date to Publish Date. References were updated. Tubing with integrated heating element for use with positive airway pressure device. 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). Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. NCD #240.4.1. 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. 2008; 162(4):350-358. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Shift work sleep disorder (SWSD): A sleep disorder that is related to unusual or constantly changing work schedules and results in symptoms of insomnia or excessive sleepiness. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. The Definitions and References were updated. But don't worry - our team will handle the legwork in getting them to your insurance company. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. The content on this website is for informational purposes only. Blue Cross and Blue Shield Assoc.
FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. %PDF-1.7
Sleep Disorders. No other changes were made to statements or criteria. CPAP machine prices start around $250 and can reach $1000 or higher.
PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL 2020; 172(5):325-336. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. Guilleminault C, Abad VC. Continued use beyond the first three (3) months of therapy Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. 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. 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 . 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. It happens when the muscles in the throat relax and block the air passages to make sure . Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. Version 2.6. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Sleep Med Rev. endobj
Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. If you're among the 2% to 9% of adults who suffer from obstructive sleep apnea, a CPAP machine may be the solution to better sleep. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. 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 This means your doctor still needs to conduct a sleep study to give you a diagnosis. A7027. Kapur VK, Auckley DH, Chowdhuri S, et al. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. Available at: Berry RB, Quan SF, Abreu AR, et al. 2004; 130(1):58-66. The potential benefits of diagnostic audio recording, used alone or in conjunction with pulse oximetry, have not been demonstrated to provide clinical benefits equivalent to PSG. 2003; 87(4):803-833. 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.
Devices Used for the Treatment of Sleep Apnea in Adults American Academy of Sleep Medicine (AASM). CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. 2017; 13(10):1199-1203. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Polysomnography (PSG) also typically includes electrocardiography and monitoring of Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Horizon Blue Cross Blue Shield of New Jersey partnered with the March of Dimes to offer an eLearning session on implicit bias called Awareness to Action: Dismantling Bias in Maternal and Infant Healthcare. 2007; 30(4):519-529. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. References were updated. Information on this website should not be construed as medical advice. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) 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. 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). You also avoid the insurance requirements of treatment compliance. 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. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Sleep Res Online. So if you're close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. Types of coverage. First, you must have a prescription for CPAP therapy from your healthcare provider.
Participating provider network for custom fitted oral sleep alliances Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. in an asymptomatic individual; 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). 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. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Your daily habits and environment can significantly impact the quality of your sleep. 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. Other criteria are unchanged for MSLT and other services. Coverage continues if your sleep apnea improves with the CPAP treatment.
Medical Policy | Blue Cross and Blue Shield of Illinois Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. 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. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Diagnosis and management of childhood obstructive sleep apnea syndrome. 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. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. Netzer NC, Stoohs RA, Netzer CM, et al. Not sure what your Blue Cross insurance covers? endobj
The members contract benefits in effect on the date that services are rendered must be used. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. 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. J Clin Sleep Med. Involuntary sleepiness during activities that require more active attention, such as talking or driving. Sleep.
BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial 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. Oral cushion for combination oral/nasal mask, replacement only, each. Report of the Swiss respiratory polygraphy registry and systematic review of the literature.
PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI On the other hand, if you have a co-insurance plan, you will also be billed monthly for the rental cost of the device, alongside your insurance company. Chesson AL Jr, Berry RB, Pack A. Strollo PJ Jr. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. AHRQ Technology Assessment Program. Sleep Diag Ther. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from 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. ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - Patient Page. 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. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. 3 0 obj
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. %PDF-1.7
Townsend D, Sharma A, Brauer E, et al. Filters, which need to be replaced frequently, run between $5 and $30 each. 1997; 20(12):1208. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Your email address will not be published. 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-
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