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. 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. Updated Coding section with 01/01/2010 CPT changes. Sleep. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. The effective date is February 26, 2018. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. American Academy of Sleep Medicine (AASM). CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Individuals have failed a prior trial of CPAP. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. The medical records must also document objective findings of compliance information, (i.e. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Typically, your deductible applies to essential CPAP equipment, not including optional accessories. Am J Respir Crit Care Med. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Criteria Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP) An APAP device or CPAP device may be considered medically necessary for the treatment of obstructive sleep apnea (OSA) in adults and covered as durable medical equipment when the following criteria are met: APAP Neurol Clin. Watanabe T, Kumano-Go T, Suganuma N, et al. He has tested hundreds of mattresses and sleep products. Silber MH. Replacement of PAP Devices Kryger MH. Nasal Expiratory Positive Airway Pressure (EPAP). 3 0 obj 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. 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. 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. Your plan may include different types of coverage, such as for health and dental. Blue Cross and Blue Shield Assoc. 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. 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. 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 . 2017; 13(3):479504. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. 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. Recommendations from other national entities may vary. ; Swiss Respiratory Polygraphy Registry. MPTAC review. Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. First, you must have a prescription for CPAP therapy from your healthcare provider. - Any additional medical records, such as your sleep study, that your insurance company requests. 2002; 165(11):1499-1503. Sleep. 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. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. Not sure what your Blue Cross insurance covers? More than 75% of the apneas or hypopneas must have an obstructive pattern. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. MPTAC review. An AHI/RDI greater than 30 is consistent with severe OSA. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. Other criteria are unchanged for MSLT and other services. If youre diagnosed with sleep apnea and require CPAP therapy, its likely your insurance will cover the cost of the device, and the replacements required thereafter. Act now to earn free CME credits and helps advance maternal health in New Jersey. Otolaryngol Head Neck Surg. 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). 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. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Sleep. CPAP machine prices start around $250 and can reach $1000 or higher. Once the 13 months have passed, you own the machine. American Academy of Sleep Medicine (AASM) 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). Standards of Practice Committee, American Academy of Sleep Medicine. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. However, none of these portable tests currently provide diagnostic information that is superior to established Type III home portable monitors (HPM), which monitor and record a minimum of four parameters: respiratory movement/effort, airflow, ECG/heart rate, and oxygen saturation. Pediatrics. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. Effective April 01, 2023. J Clin Sleep Med. Continued use beyond the first three (3) months of therapy. 3 0 obj 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. <> 2007; 1:1-8. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. Flemons WW. 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. This is a unique virtual learning experience for health care professionals caring for women and . You must also adhere to the same compliance requirements as Medicare recipients, namely using the machine at least 4 hours every night on 70% of nights. J Clin Sleep Med. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. MPTAC review. Strollo PJ Jr. 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. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 Sleep. Thanks for the feedback - we're glad you found our work instructive! Nap study: This term refers to a shorter daytime version of a PSG sleep study. 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. 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. 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. 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. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. J Clin Sleep Med. These include: Insurance does not typically cover any products that are considered optional. 2001; 19(1):173-186. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Oral cushion for combination oral/nasal mask, replacement only, each. These tests vary in the number and nature of sleep parameters that are measured, in order to gain an understanding of the conditions under which sleep disturbances occur. Your daily habits and environment can significantly impact the quality of your sleep. 1. m|(=IPYAcmAa#nhwRz(v^6;Ut4?o+UIv(($HSnG>:~;khOFtUG+'@Gq^B0kT$Ae/a#*lJk=aZdj~\:POhI-y p;6p=E?t:M?h=U,>) ]1r!!pr8lDbDadJJV|p6l-Dq. 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. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. 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. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. - Comfort Products: Mask Liners, Creams, etc. Liners are not interfaces for use with a PAP mask. Annals Intern Med. Policy Statement . endobj Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: Guidelines are designed to support the decision-making processes in patient care. 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 2019; 10:551. If the criteria are not met, the accessories are considered not medically necessary. State Medicaid programs typically follow the same guidelines as Medicare. 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). Your doctor must determine which type of study is right for you. 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.
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