Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. Medical Management of Obstructive Sleep Apnea Syndrome Policy # 00328 Original Effective Date: 07/27/2012 Current Effective Date: 01/09/2023 2022 Blue Cross and Blue Shield of Louisiana . Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. Front Psychiatry. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. Billing for each individual component is considered unbundling of these supplies. 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- Combination oral/nasal mask, used with continuous positive airway pressure device, each. 2011; 7(5):531-548. The medical records must also document objective findings of compliance information, (i.e. Ann Intern Med. The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. stream A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. A clarification was made within the Definitions section regarding severe OSA as being defined as an RDI/AHI of greater than 30 (not 40). First, you must have a prescription for CPAP therapy from your healthcare provider. 2005; 128(4):2166-2175. eligible for coverage. Medical Policy & Technology Assessment Committee (MPTAC) review. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. BCBS of Kansas, which covers approximately 560,000 members.. Act now to earn free CME credits and helps advance maternal health in New Jersey. 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". Anthems insurance plans will cover CPAP supplies that are deemed a medical necessity for OSA (obstructive sleep apnea), such as: However, the cost of other accessories for your CPAP machine, including things like cleaning devices or wipes, batteries, or duplicate machines such as travel versions, will not be covered. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. N Engl J Med. Marcus CL, Brooks LJ, Draper KA, et al. 4 0 obj Costs for these products can vary depending on the quality. 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. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . MPTAC review. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. 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). endobj %PDF-1.7 Costs for purchasing a machine outright can range anywhere from $250 to $1,000 or more, depending on where you live and the type of machine you need. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Townsend D, Sharma A, Brauer E, et al. The most common options include: Medicare may cover a 3-month trial of CPAP therapy, and they may cover it longer if your doctor documents in your medical record that you meet certain conditions regarding the use of the device and they claim that the CPAP therapy is helping you. When you buy through our links, we may earn a commission. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. 2013; 9(2):125-131. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Dise Is A Prerequisite To Inspire BOTH If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. MPTAC review. CPAP therapy is effective, but it can also be expensive. O'Driscoll DM, Foster AM, Davey MJ, 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. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. The Eccovision Acoustic Reflection Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. CPAP machine prices start around $250 and can reach $1000 or higher. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. 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 J Clin Sleep Med. Five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention); Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses) and. D'Andrea LA. 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. endobj Updated coding: Added CPT code 95806 and 0089T; removed CPT codes 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145, 95806, 95808, 95810, 95811, 99508; removed ICD-9 Procedure codes 76.62, 76.63, 76.64, 76.65, 76.66, 89.17; removed HCPCS codes E0561, E0562, E0601, K0183, K0189, K0268, K0531, K0532, K0533, S8260, D7940, D7944, D7946, D7947, D7948, D7949, D7950, D7950, D7995, D7996, S2080, 0088T. That said, coverage varies depending on your plan, insurance company, and authorization requirements. The application of each Blue Shield of California medical policy is subject to regulatory requirements and/or plan specific benefits and limitations (Evidence of Coverage - EOC). Available at: Morgenthaler T, Alessi C, Friedman L, et al. Fargo, N.D., 58121. Arch Fam Med. Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based PSG or with a positive home/portable sleep test); AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual. Arch Pediatr Adolesc Med. Government Agency, Medical Society, and Other Authoritative Publications: ActigraphyApnea/Hypopnea Index (AHI)Apnea Risk Evaluation System (ARES)Nap StudyObstructive Sleep Apnea (OSA)Pharyngometry AcousticQuantitative EEG MappingSleepStripSNAP Testing SystemStatic Charge Sensitive BedsTopographic EEG Mapping. 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. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subjects movement over a period of time. endobj As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. 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. If you are on a rent-to-own structure, your monthly fee typically equals the cost of the CPAP machine divided by the number of rental months. 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 equipmentandmeetALLof the following criteria: Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA whenALLof the following criteria are met: 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. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. The two main types of sleep apnea are: Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. July 15, 2018. Updated the formatting of the Position Statement section. Respiratory polygraphy in sleep apnea diagnosis. 2003, 24(2):307-313. Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; The individual is experiencing success in treatment. is found to be more effective in the sleep lab to be . Most CPAP machines cost between $500 and $800. C. Recent Home Sleep Apnea Test (HSAT) (less than 1 year old) confirmed to be non-diagnostic: 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. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. Your email address will not be published. Our site does not include the entire universe of available offers. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. Am J Respir Crit Care Med. Medical policy list. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. 1997; 20(6):423-487. Kryger MH. Updated Coding section with 01/01/2010 CPT changes. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. 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 MPTAC review. Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. 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 These are not considered interfaces as defined in this policy. Save my name, email, and website in this browser for the next time I comment. Arch Dis Child. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Removed ICD-9 codes from Coding section. 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. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 2002; 165(11):1499-1503. You also avoid the insurance requirements of treatment compliance. Sleep Res Online. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. 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). 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). Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. J Clin Sleep Med. Effective April 01, 2023. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. Most other equipment ranges between $20 and $100. 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. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 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. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. Werner H, Molinari L, Guyer C, Jenni OG. Available at. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . - Any additional medical records, such as your sleep study, that your insurance company requests. ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - Masks often cost $100 or more, and other equipment ranges between $20 and $100. Med Clin North Am. AHRQ Technology Assessment Program. References were updated. The criteria for home portable monitors/sleep testing have been removed from this document and placed in CG-MED-01 Polysomnography and Home Portable Monitors. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. The machine attaches to a mask that you wear over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open. 1997; 20(6):406-422. Annals Intern Med. Recommendations from other national entities may vary. 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. Available at: Thurnheer R, Bloch KE, Laube I, et al. Click the button below to submit your insurance information to us and get started! <> 2013; 36(11):1747-1755. A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. 1. Learn more. 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. Centers for Medicare and Medicaid Services. 2019; 10:551. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> 2007; 30(4):519-529. 2007; 146(3):157-166. Sleep Med Rev. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. 2002; 109(4):e69. If youve been diagnosed with sleep apnea, its likely that youll need a CPAP mask, as this is considered the best course of treatment for the condition. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Yes! SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders.