National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. References and Coding were updated. Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. MPTAC review. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 Portable Monitoring Task Force of the American Academy of Sleep Medicine. American Sleep Disorders Association and Sleep Research Society. . This document addresses selected services for the diagnosis of sleep disorders including: Investigational and Not Medically Necessary: Nap studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy. Patient-Centered Medical Home A patient-centered medical home is a new type of health care that makes you part of the team. 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. Dise Is A Prerequisite To Inspire Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. 2 0 obj SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. 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. Fletcher EC, Stich J, Yang KL. The Definitions and References were updated. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. O'Driscoll DM, Foster AM, Davey MJ, et al. 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. Townsend D, Sharma A, Brauer E, et al. According to the American Academy of Sleep Medicine (AASM), updated definitions of OSA severity are provided as follows: Mild OSA: AHI of 5-15, involuntary sleepiness during activities that require little attention, such as watching TV or reading; Moderate OSA: AHI of 15-30, involuntary sleepiness during activities that require some attention, such as meetings or presentations; Severe OSA: AHI of more than 30, involuntary sleepiness during activities that require more active attention, such as talking or driving (AASM, 2008). Effective March 3, 2009. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. An independent member of the Blue Shield Association 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome Original Policy Date: April 3, 2009 Effective Date: October 1, 2022 Section: 2.0 Medicine Page: Page 1 of 26 . Respicardia Announces Highmark Coverage for the rem Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Marino M, Li Y, Rueschman MN, et al. PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI JAMA. Kapur VK, Auckley DH, Chowdhuri S, et al. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application A7028. 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. That said, coverage varies depending on your plan, insurance company, and authorization requirements. 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. Payment may be made for one (1) appliance. CPAP therapy is effective, but it can also be expensive. Once the 13 months have passed, you own the machine. Effective April 01, 2023. Continued use beyond the first three (3) months of therapy If youre among the 2% to 9% of adults who suffer from obstructive sleep apnea, a CPAP machine may be the solution to better sleep. Sleep Res Online. 2019; 46:151-160. Obstructive sleep apnea syndromes. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. Trikalinos TA, Ip S, Raman G, et al. Note: Ann Intern Med. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Benefits Application This medical policy relates only to the services or supplies described herein. It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. American Academy of Sleep Medicine (AASM). 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. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing. Providers have the opportunity to review . MPTAC review. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. Therefore, it is particularly important that individuals with severe OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. 1999; 131(7):485-491. 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. 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). Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: 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. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Medical Policy | Blue Cross and Blue Shield of Illinois 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. Efforts are made to maintain reliable data on all information presented. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Available at: Morgenthaler T, Alessi C, Friedman L, et al. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. 2010; 95(12):1031-1033. 2000; 3(4):169-172. State of South Carolina - Coverage Information 2008; 162(4):350-358. 2001; 19(1):173-186. Your plan may include different types of coverage, such as for health and dental. The exclusion of obstructive sleep apnea (OSA) as the predominant cause of sleep-associated hypoventilation; For BPAP-ST, the ruling out of CPAP as effective therapy if OSA is a component of the sleep-associated hypoventilation; Significant improvement of the sleep-associated hypoventilation with the use of either PAP device on the settings that will be prescribed for initial use at home, while breathing the individual's prescribed FIO2. Inspire Medical Systems - creator of a pacemaker-like system to treat obstructive sleep apnea - said today that the Blue Cross Blue Shield Association's Evidence Street issued a positive . Breathing Problems during Sleep. 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. 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. 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. 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. Participating provider network for custom fitted oral sleep alliances Hypopnea: Breathing that is more shallow, and/or slower, than normal. Darien, IL: AASM; 2020. Filters, which need to be replaced frequently, run between $5 and $30 each. Inspire Medical Systems scores win with Blue Cross Blue Shield It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. 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. Ann Intern Med. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. <>/Metadata 1019 0 R/ViewerPreferences 1020 0 R>> Required fields are marked *. References were updated. Other insurance providers may have different standards. Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. 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 Most insurance plans partially cover the costs of CPAP machines and related equipment. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. JAMA. Replacement of PAP Devices Revisions also made to Coding section for clarification of MWT coding. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. 2003, 26(7):907-913. BCN Sleep Management Program (Testing and Treatment with - BCBSM Medically necessary criteria regarding Type III home portable devices were updated with information about newer models of the SNAP devices that are considered Type III devices. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. It isnot intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. OPT devices (e.g., Winx Sleep Therapy System) are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. Mysliwiec V, Martin JL, Ulmer CS, et al. 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. Nasal EPAP devices (e.g., Provent, Theravent) are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. American Academy of Sleep Medicine (AASM). PDF Medical Policy - Sleep Disorders, Diagnosis and Medical Management J Clin Sleep Med. endobj PAP devices may improve quality of life in individuals with sleep apnea in adults. Sleep Disorders. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. American Academy of Sleep Medicine (AASM) How Often Does Insurance Cover a New CPAP Machine? First, you must have a prescription for CPAP therapy from your healthcare provider. endobj Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. stream Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) <> Westchester, IL: American Academy of Sleep Medicine; 2007. 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. - Blue Cross and Blue Shield's Federal Employee Program PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. 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. MPTAC review. Flemons WW, Littner MR, Rowley JA, et al. 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. - Any additional medical records, such as your sleep study, that your insurance company requests. Indications for treatment of obstructive sleep apnea in adults. All rights reserved. More than 75% of the apneas or hypopneas must have an obstructive pattern. eligible for coverage. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. endobj Either a heated humidifier or a non-heated humidifier is eligible for use with a covered PAP device when prescribed by the treating physician to meet the needs of the individual. Risk factors for obstructive sleep apnea in adults. References were updated. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. Home diagnosis of sleep apnea: a systematic review of the literature. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. 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. Young T, Skatrud J, Peppard PE. Sleep apnea is a harmful condition that can have substantial negative impacts on health.