blue cross blue shield sleep apnea coverage

American Academy of Sleep Medicine (AASM) A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. 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). 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. Med Clin North Am. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . This change was approved at the November 29, 2007 MPTAC meeting. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. Marcus CL, Brooks LJ, Draper KA, et al. 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. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. PAP (positive airway pressure) Machines and Humidifiers, Typically, filter replacements are every 30 days, Typically, tubing replacements are every 3 months, Typically, mask replacements are every 3 months, 3-month rental, 4th-month purchase (many PPO insurances), 10-month rental (most HMO insurance and some PPO insurances), 13-month rental (Medicare and other government insurance). Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. 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 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. The terms of your CPAP machine, insurance coverage depends on your provider. Because CPAP machines and their tubing are required daily, theyre subject to significant wear and tear, so you may be wondering how often insurance will cover CPAP supplies. Watanabe T, Kumano-Go T, Suganuma N, et al. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Diagnosis and management of childhood obstructive sleep apnea syndrome. 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. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. 2007; 1:1-8. Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. You also avoid the insurance requirements of treatment compliance. 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 . Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. 1999; 131(7):485-491. Continued use beyond the first three (3) months of therapy Payment will be made for the purchase of the device whenBOTHof 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. Removed ICD-9 codes from Coding section. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Available at. JAMA. Olejniczak PW, Fisch BJ. 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 is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). Townsend D, Sharma A, Brauer E, et al. stream Kapur VK, Auckley DH, Chowdhuri S, et al. Collop NA, Anderson WM, Boehlecke B, et al. 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. J Clin Sleep Med. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. 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. 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. 2008; 162(4):350-358. BOTH Kryger MH. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. 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. Well cover some of the most common insurance policies surrounding CPAP equipment. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. 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. Billing for each individual component is considered unbundling of these supplies. Medical policy list. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. No other changes were made to statements or criteria. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 3 0 obj Your doctor must determine which type of study is right for you. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. This means your doctor still needs to conduct a sleep study to give you a diagnosis. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. We regularly assess how the content in this article aligns with current scientific literature and expert recommendations in order to provide the most up-to-date research. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. The Definitions and References were updated. 1 0 obj Flemons WW, Littner MR, Rowley JA, et al. J Clin Sleep Med. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. 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. If you're ready for more, sign up to receive our email newsletter! Nap study: This term refers to a shorter daytime version of a PSG sleep study. ** Medical Management of Obstructive Sleep Apnea Syndrome 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. Best Anti-Snoring Mouthpieces & Mouthguards, CPAP: Continuous Positive Airway Pressure, Link Between Sleep Apnea and Heart Disease, Medical and Brain Conditions That Cause Excessive Sleepiness, Drowsiness or falling asleep while driving, You have an hourly AHI between 5 and 14 and a, AHI index between 5 and 14, along with a comorbidity related to obstructive sleep apnea; or. 2000; 9(2):168-174. (such as sleep studies, CT scans) . This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. Masks often cost $100 or more, and other equipment ranges between $20 and $100. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. Insurance plans can significantly help defray the cost of a CPAP machine. Trikalinos TA, Ip S, Raman G, et al. 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. 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. Be sure to check your insurance policy to determine your specific requirements. 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. 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- %PDF-1.7 2008; 31(1):141-147. Then there are supplies that need to be replaced over time, including: The costs for each component vary. 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. Replacement of PAP Devices Guidelines are designed to support the decision-making processes in patient care. for the American Academy of Sleep Medicine. endobj 2004; 8(3):611-630. Risk factors for obstructive sleep apnea in adults. 2019; 10:551. 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). Policy and Coverage Criteria for Commercial Products: . Once the 13 months have passed, you own the machine. 2019; 46:151-160. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. Involuntary sleepiness during activities that require some attention, such as meetings or presentations. Available at: Morgenthaler T, Alessi C, Friedman L, et al. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. 2003; 124(4):1543-1579. Netzer NC, Stoohs RA, Netzer CM, 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. 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. Sleep education. Available at: Berry RB, Quan SF, Abreu AR, et al. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. Chesson AL Jr, Berry RB, Pack A. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Your prescription may display an expiration date, in which case it will be valid until this date. Our site receives compensation from many of the offers listed on the site. 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. Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Types of coverage. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. 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. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. 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. More than 75% of the apneas or hypopneas must have an obstructive pattern. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information.

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