Our site does not include the entire universe of available offers. Most insurance plans partially cover the costs of CPAP machines and related equipment. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: 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. 1997; 127(8 Pt 1):581-587. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. Seen as youll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the individual may be switched to BiPAP; For whom BiPAP is found to be more effective in the sleep lab. 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. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Costs for these products can vary depending on the quality. Mysliwiec V, Martin JL, Ulmer CS, et al. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Levenson JC, Troxel WM, Begley A, et al. J Clin Sleep Med. Effective March 3, 2009. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. 2002; 347(7):498-504. 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. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. %PDF-1.7 Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Oral cushion for combination oral/nasal mask, replacement only, each. Note: First, you must have a prescription for CPAP therapy from your healthcare provider. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. J Clin Sleep Med. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. 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. Sleep Diag Ther. endobj With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. Billing for each individual component is considered unbundling of these supplies. Excessive daytime sleepiness: This refers to a condition where a person feels very drowsy during the day, even after getting adequate nighttime rest, and has a tendency to fall asleep or requires extra effort to avoid sleeping in inappropriate situations, such as at work or driving. PDF Criteria Revised for Diagnosis and Treatment of Obstructive Sleep Apnea for MPTAC review. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. 2000; 3(4):169-172. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. The Definitions and References were updated. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Ann Intern Med. Patient Page. 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. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. American Academy of Sleep Medicine (AASM). 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. Individuals have failed a prior trial of CPAP. - Blue Cross and Blue Shield's Federal Employee Program These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. %PDF-1.7 American Academy of Sleep Medicine (AASM). Medical Policy & Technology Assessment Committee (MPTAC) review. Hypopnea: Breathing that is more shallow, and/or slower, than normal. 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. J Clin Sleep Med. 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). <> Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. 1 0 obj Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. Continuous positive airway pressure (CPAP): This is a noninvasive treatment for OSA that involves delivery of pressurized air during sleep through a device that snugly covers the nose. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . 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. 2008; 31(1):141-147. 2000; 9(2):168-174. No other changes were made to statements or criteria. endobj Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. The indications for polysomnography and related procedures. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. Replacement of PAP Devices Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. More expensive accessories often come with warranties of 1 to 3 years. Breathing Problems during Sleep. Practice Parameters for the Indications for Polysomnography and Related Procedures. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. Insurance plans can significantly help defray the cost of a CPAP machine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. CardioMEMSHeart Failure (HF) System coverage criteria has been relocated from stream Addition of medically necessary criteria for home/portable sleep studies to confirm diagnosis of obstructive sleep apnea. Only 10% allow for more frequent replacement. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. 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. Morgenthaler TI, Aurora RN, Brown T, et al. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. MPTAC review. - Comfort Products: Mask Liners, Creams, etc. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. Olejniczak PW, Fisch BJ. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 Efforts are made to maintain reliable data on all information presented. Easy Breathe is one of the only online CPAP providers able to bill insurance. 3 months/90 days. Swiss Med Wkly. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. These coverage types are separate from one another. 2 0 obj Extended! Free CME credits for Training On Bias in Maternal Health Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. Trikalinos TA, Ip S, Raman G, et al. Guilleminault C, Abad VC. Removed ICD-9 codes from Coding section. 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. Medical policy list. Tubing with integrated heating element for use with positive airway pressure device. This limits your coverage options, and you may not get the exact product you desire. 2002; 109(4):e69. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. Obstructive sleep apnea. Chesson AL Jr, Ferber RA, Fry JM, et al. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. References were updated. 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. It happens when the muscles in the throat relax and block the air passages to make sure . 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. 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. Your plan may include different types of coverage, such as for health and dental. 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. A7028. Townsend D, Sharma A, Brauer E, et al. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. This change affects all providers that manage sleep-related care for . If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> Sleep education. Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnea, as long as you meet the following requirements: You must also meet Medicares compliance requirements, which state that you must use the machine at least 4 hours per night, 70% of the time or more, during the first 3 months. Blue Care Network's medical policy on the diagnosis and management of obstructive sleep apnea includes coverage for home sleep studies for members with symptoms of OSA without other comorbid conditions. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. 1997; 20(6):406-422. Hypertension 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. 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". Revisions also made to Coding section for clarification of MWT coding. actigraphy, including use of static charge sensitive beds; diagnostic audio recording, with or without pulse oximetry to document sleep apnea; Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea; Actigraphy or static charge sensitive beds. Once the 13 months have passed, you own the machine. Conley S, Knies A, Batten J, et al. 2002; 165(11):1499-1503. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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]. Additional appliances should be denied as not medically necessary. This is a unique virtual learning experience for health care professionals caring for women and . 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. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline.
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