blue cross blue shield sleep apnea coverage

Updated the formatting of the Position Statement section. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. J Clin Sleep Med. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. First, you must have a prescription for CPAP therapy from your healthcare provider. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. Trikalinos TA, Ip S, Raman G, et al. Neurol Clin. Practice parameters for using polysomnography to evaluate insomnia: an update. New Policy for Obstructive Sleep Apnea (OSA) and Sleep Devices Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Inspire Medical Systems scores win with Blue Cross Blue Shield Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. If you require more frequent replacements of certain components, those costs may be out of pocket. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Positive Airway Pressure (PAP) Supplies - Regence References and Coding sections were also updated. References were updated. 2007; 3(7):737-747. 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. The indications for polysomnography and related procedures. Close follow-up for PAP device usage and problems in individuals with sleep apnea by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems if needed. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Diagnosis and management of childhood obstructive sleep apnea syndrome. 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. <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> 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. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. For general information about AIM Specialty Health, call 1-847-564-8500, Monday through Friday, from 9 a.m. to 6 p.m., Eastern Time (ET). Billing for each individual component is considered unbundling of these supplies. Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. References were updated. Clinical Practice Guidelines | Blue Cross and Blue Shield of Illinois After reading and interpreting the results of your sleep study, your doctor may diagnose you with sleep apnea and work with you to develop a treatment plan. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome - Blue Shield of ** Medical Management of Obstructive Sleep Apnea Syndrome 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. 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. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC 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). Sleep. CPAP therapy is effective, but it can also be expensive. Participating provider network for custom fitted oral sleep alliances American Academy of Sleep Medicine. American Sleep Disorders Association and Sleep Research Society. 2007; 16(2):213-216. 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. 2023 Blue Cross Blue Shield of North Dakota, Please wait while your form is being submitted, Devices Used for the Treatment of Sleep Apnea in Adults, 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. 1999; 131(7):485-491. 2021 cpaphackers.com | All rights reserved. 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. J Clin Sleep Med, 2018; 14(7):1231-1237. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis. Sleep Disorders. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage AHRQ Technology Assessment Program. A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone (PAT), oximetry and actigraphy may be considered 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. for the American Academy of Sleep Medicine. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. MPTAC review. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. The use of specific product names is illustrative only. - Blue Cross and Blue Shield's Federal Employee Program However, the utility of acoustic pharyngometry measurement in the clinical setting of OSA has not been demonstrated, and it remains unclear how this test will impact treatment planning and clinical outcomes. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. 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. Oxygen saturation measures the significance of respiratory events. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. The Definitions and References were updated. 2004; 130(1):58-66. Available at: Journal of the American Medical Association. A provider's office can often get an immediate approval when they submit a request online. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. J Clin Sleep Med. 2 0 obj Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . 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. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Coverage | BlueCross BlueShield of South Carolina BiPAP without back-up rate may be considered medically necessary for the treatment of OSA in adults and may be considered as durable medical equipment when the following criteria are met: BiPAP without back-up rate devices not meeting the criteria as indicated in this policy are considered not medically necessary. According to the OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Sleep apnea is a harmful condition that can have substantial negative impacts on health. 3 0 obj Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. The Rationale, Definitions and References were updated. 1997; 20(6):423-487. The members contract benefits in effect on the date that services are rendered must be used. Obstructive sleep apnea syndromes. Marcus CL, Brooks LJ, Draper KA, et al. 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. Flemons WW. Combination oral/nasal mask, used with continuous positive airway pressure device, each. Extended! Free CME credits for Training On Bias in Maternal Health Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. There is additionally a vital hereditary component to the disease. Most CPAP machines cost between $500 and $800. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Am J Respir Crit Care Med. MPTAC review. When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. Centers for Medicare and Medicaid Services. Westchester, IL: American Academy of Sleep Medicine; 2007. Watanabe T, Kumano-Go T, Suganuma N, et al. Our site receives compensation from many of the offers listed on the site. References were updated. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. MPTAC review. 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. 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. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance Rationale section was updated with information about acoustic pharyngometry and SNAP testing. However, how often they replace these, and how much of the cost your insurance covers, of course depends on your policy and the company youre with. 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. American Academy of Pediatrics (AAP). PDF 969 Sleep Disorder Management - bluecrossma.org BOTH Other criteria are unchanged for MSLT and other services. 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. Some rental plans may include the cost of replacement equipment, which is something to bear in mind when comparing the cost of buying outright versus going with insurance. More than 75% of the apneas or hypopneas must have an obstructive pattern. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. Annals Intern Med. Take the Sleep Quiz to help inform your sleep improvement journey. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. NCD #240.4.1. A clarification was made within the Definitions section regarding severe OSA as being defined as an RDI/AHI of greater than 30 (not 40).

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