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. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. It happens when the muscles in the throat relax and block the air passages to make sure . Pediatrics. Darien, IL: AASM; 2020. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Oct 1, 2020 Administrative. If the CPAP therapy helps improve your sleep apnea symptoms during the 12-week period, Medicare continues to cover the cost of your CPAP equipment. 2002; 165(11):1499-1503. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . Sleep Disorders. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Liners are not interfaces for use with a PAP mask. Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. If you're ready for more, sign up to receive our email newsletter! Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements. MPTAC review. 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. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. Version 2.6. 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. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. Standards of Practice Committee of the American Sleep Disorders Association. 2004; 8(3):611-630. References and Coding were updated. The Rationale, Definitions and Reference sections have also been updated. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. 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. Sleep. BCBSNC will provide coverage for surgery for obstructive sleep apnea and upper airway resistance syndrome when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. 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. American Academy of Sleep Medicine. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. Note:See the table below for the usual maximum amount of accessories considered to be medically necessary. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. Please refer to the members contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. Your email address will not be published. This means your doctor still needs to conduct a sleep study to give you a diagnosis. Bi-level Positive Airway Pressure(BiPAP) without back-up rate. 2005; 128(4):2166-2175. Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. CPT Only - American Medical Association, https://jcsm.aasm.org/doi/10.5664/jcsm.7230, https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&, http://aasmnet.org/Resources/PracticeParameters/Outofcenter.pdf, http://jcsm.aasm.org/ViewAbstract.aspx?pid=30972, http://pediatrics.aappublications.org/content/130/3/576.full.pdf+html, https://aasm.org/aasm-introduces-new-patient-education-website-sleepeducation-com/, http://jama.ama-assn.org/cgi/reprint/285/22/2936?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=Patient+page%3A++Breathing+problems+during+sleep&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: 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 policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. References were updated. stream Again, this will depend on your individual insurance plan and provider, but in the case of Anthem they offer the following replacement schedule: Generally speaking, most insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. 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- 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. 2008; 31(1):141-147. 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 Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. 2003; 124(4):1543-1579. 1996; 11(2). Revisions also made to Coding section for clarification of MWT coding. <> Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. Involuntary sleepiness during activities that require more active attention, such as talking or driving. endobj Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. These include: Insurance does not typically cover any products that are considered optional. 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. Continued use beyond the first three (3) months of therapy. Werner H, Molinari L, Guyer C, Jenni OG. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. J Clin Sleep Med. Trikalinos TA, Ip S, Raman G, et al. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. 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]. Along with key review factors, this compensation may impact how and where products appear across the site (including, for example, the order in which they appear). A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. 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. AHRQ Technology Assessment Program. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. Liners are not interfaces for use with a PAP mask. Patient Page. 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. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Be sure to check your insurance policy to determine your specific requirements. Sleep Apnea. Your email address will not be published. Available at: Berry RB, Quan SF, Abreu AR, et al. Am J Respir Crit Care Med. 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. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. These coverage types are separate from one another. SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. CPAP machine prices start around $250 and can reach $1000 or higher. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. BCBSNC will provide coverage for Diagnosis and Medical Management of Sleep Apnea when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. While the use of actigraphy has been demonstrated to be useful in the detection of sleep problems in healthy or normal individuals, potential benefits for individuals with suspected sleep disorders have not been shown. Sleep. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. 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. MPTAC review. Littner M, Hirshkowitz M, Kramer M, et al. The content on this website is for informational purposes only. 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. Practice parameters for using polysomnography to evaluate insomnia: an update. MPTAC review. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . Typically, your deductible applies to essential CPAP equipment, not including optional accessories. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. 2003, 26(7):907-913. 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. Medical Policy & Technology Assessment Committee (MPTAC) review. 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. Providers have the opportunity to review . An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application 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. 2002; 109(4):e69. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.
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