Once the 13 months have passed, you own the machine. 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). Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based polysomnogram (PSG) or with a positive home/portable sleep test); Greater than or equal to 15 events per hour of sleep in an asymptomatic individual; Greater than 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). Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Med Clin North Am. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. 2000; 3(4):169-172. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. Review your policy to learn about the requirements specific to your insurance provider. 2007; 16(2):213-216. Most machines record your use for you. 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. Swiss Med Wkly. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Chest. Front Psychiatry. Your doctor will first check for symptoms of obstructive sleep apnea, including: If your symptoms indicate you might have obstructive sleep apnea, the next step is to take a sleep study. Chesson AL Jr, Ferber RA, Fry JM, et al. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Darien, IL: AASM; 2020. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. The machine is returned to the doctor the following morning for data analysis. 1997; 20(6):406-422. The following diagnostic tests are considered investigational and not medically necessary: The evidence in the medical literature does not support the use of single nap studies. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. 2017; 13(3):479504. PAP devices have directions from the manufacturing company included for cleaning. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. This condition is associated with frequent awakening and often with daytime sleepiness. If you require more frequent replacements of certain components, those costs may be out of pocket. Additional appliances should be denied as not medically necessary. J Clin Sleep Med. There are many different types of sleep-related disorders, including obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), insomnia, narcolepsy, nocturnal movement disorders, such as Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD), unexplained excessive daytime sleepiness, and arousal disorders (parasomnias). 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). Strollo PJ Jr. 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). Trikalinos TA, Ip S, Raman G, et al. 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. x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Sleep education. %PDF-1.7 The members contract benefits in effect on the date that services are rendered must be used. endobj 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. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. 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. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. 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. Townsend D, Sharma A, Brauer E, et al. Mulgrew AT, Fox N, Ayas NT, Ryan CF. 1. Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. CPAP machine prices start around $250 and can reach $1000 or higher. Dise Is A Prerequisite To Inspire Not sure what your Blue Cross insurance covers? Sleep. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: MPTAC review. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. Costs for these products can vary depending on the quality. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. 2 0 obj Another type of sleep disturbance is simply known as apnea or central apnea. This condition, caused by problems in the central nervous system, is unrelated to OSA and is not addressed in this document. Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. This change was approved at the November 29, 2007 MPTAC meeting. Marcus CL, Brooks LJ, Draper KA, et al. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). Patient Page. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Morgenthaler TI, Aurora RN, Brown T, et al. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 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. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. 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. 2002; 109(4):e69. 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 . Available at. Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. The Rationale, Definitions and References have been updated. 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. 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- 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. Practice parameters for using polysomnography to evaluate insomnia: an update. This change affects all providers that manage sleep-related care for . Bi-level Positive Airway Pressure(BiPAP) without back-up rate. 1 0 obj If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. The medical records must also document objective findings of compliance information, (i.e. 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. Sleep Disorders. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. 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. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. Internal Medical Policy Committee 11-23-2021 Revised the way the not medically necessary statements were written; added Daytime electrical stimulation (eXciteOSA) of the tongue. % However, this information is provided without warranty. JAMA. Guidelines are designed to support the decision-making processes in patient care. 2003, 26(7):907-913. MPTAC review. 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. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. Sleep Disorders. Fargo, N.D., 58121. Sleep Med Rev. Narcolepsy: This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy). American Sleep Disorders Association and Sleep Research Society. It happens when the muscles in the throat relax and block the air passages to make sure . Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Payment will be made for the purchase of the device when If you have any questions about the guidelines, or wish to provide feedback, this can be done by contacting the Quality Improvement Department at 312-653-3465. An American Sleep Disorders Association Report. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Centers for Medicare and Medicaid Services. Breathing Problems during Sleep. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. If the criteria are not met, the accessories are considered not medically necessary. The criterion standard diagnostic test for sleep disorders is a polysomnogram performed in a sleep laboratory.2 A standard polysomnogram includes EEG, submental electromyogram (EMG) and electrooculogram (to detect rapid eye movement [REM] sleep) for sleep staging. 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. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). 2003, 24(2):307-313. These are not considered 'interfaces' as defined in this policy. Yes! No other changes were made to statements or criteria. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. The terms of your CPAP machine, insurance coverage depends on your provider. Hypertension Programs and resources to help you prevent and manage hypertension. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. PAP devices may improve quality of life in individuals with sleep apnea in adults. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. O'Driscoll DM, Foster AM, Davey MJ, et al. 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. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. <> Diagnosis and management of childhood obstructive sleep apnea syndrome. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. Arch Pediatr Adolesc Med. This is a unique virtual learning experience for health care professionals caring for women and . Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. minimally invasive solutions for patients with obstructive sleep apnea, announced today that three new Blue Cross Blue Shield Association ("BCBSA") healthcare plans have issued positive coverage policies of Inspire therapy. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. 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. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. 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). MPTAC review. If your insurance company determines you are not using the machine frequently enough as per your policy, they may stop covering their portion of the machine rental. More expensive accessories often come with warranties of 1 to 3 years. 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. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) J Clin Sleep Med, 2018; 14(7):1231-1237. 2004; 130(1):58-66. These coverage types are separate from one another. Pediatrics. - Comfort Products: Mask Liners, Creams, etc. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. Pediatrics. Sleep. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) MPTAC review. 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. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run.

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