Effective March 3, 2009. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> CPAP therapy is effective, but it can also be expensive. Easy Breathe is one of the only online CPAP providers able to bill insurance. Ann Intern Med. Products or services advertised on this page may be offered by an entity that is affiliated with us. Typically, your deductible applies to essential CPAP equipment, not including optional accessories. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. The indications for polysomnography and related procedures. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. <> Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Save my name, email, and website in this browser for the next time I comment. There is no additional payment for liners used with a PAP mask. 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. Insurance plans can significantly help defray the cost of a CPAP machine. Technology Evaluation Center (TEC) assessments. 2019; 10:551. Dise Is A Prerequisite To Inspire This is a unique virtual learning experience for health care professionals caring for women and . 2012; 130(3):576-584. (such as sleep studies, CT scans) . Netzer NC, Stoohs RA, Netzer CM, et al. 2007; 146(3):157-166. 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 Pediatrics. Sleep Diag Ther. A7027. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . The medical records must also document objective findings of compliance information, (i.e. endobj MPTAC review. Interpretation Obstructive Sleep Apnea (OSA) syndrome consists of a collection of symptoms including daytime sleepiness, fatigue, snoring, and restless sleep with a disrupted sleep pattern. Most machines record your use for you. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. 2007; 16(2):213-216. If you fail to meet these requirements, you have to begin the process again. Medical Policy & Technology Assessment Committee (MPTAC) review. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. endobj 2002; 165(11):1499-1503. 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. Standards of Practice Committee of the American Sleep Disorders Association. 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. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. Revisions also made to Coding section for clarification of MWT coding. Filters, which need to be replaced frequently, run between $5 and $30 each. N Engl J Med. stream Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. 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 or CPAP devices not meeting the criteria as indicated in this policy are considered not medically necessary. Want to read more about all our experts in the field? More expensive accessories often come with warranties of 1 to 3 years. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. 1 0 obj Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. All rights reserved. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Medical policy list. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. American Academy of Sleep Medicine. 2004; 51(1):169-186. JAMA. 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. 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. 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). There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. Flemons WW, Littner MR, Rowley JA, et al. When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. E NCD #240.4.1. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Risk factors for obstructive sleep apnea in adults. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. Chest. Payment may be made for one (1) appliance. 2 0 obj 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. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. J Clin Sleep Med. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. 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. 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. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Individuals have failed a prior trial of CPAP. Your email address will not be published. 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 individuals physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. Hypertension 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). Sleep Disorders. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Before making a final decision, please read the Plan's federal brochure (RI 71-005). Continued use beyond the first three (3) months of therapy 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. <> 2004; 8(3):611-630. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. 2003; 124(4):1543-1579. More than 75% of the apneas or hypopneas must have an obstructive pattern. Swiss Med Wkly. 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). Your plan may include different types of coverage, such as for health and dental. 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. 1999; 131(7):485-491. 2010; 95(12):1031-1033. 2000; 3(4):169-172. 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. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. 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. Westchester, IL: American Academy of Sleep Medicine; 2007. Payment will be made for the purchase of the device when A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. - Travel CPAPs: Insurance will not cover a second accessory CPAP for travel. 2004; 291(16):2013-2016. Obstructive sleep apnea syndromes. 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. Available at. Wide deviations in the conditions and data collection methods available cause significant variability in the outcomes of these studies and do not allow for proper sleep assessment. 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. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. 1. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Contact Carelon online via Carelon's ProviderPortalor call toll-free at 1 (877) 291-0509, 8 a.m. - 5 p.m. PST Monday through Friday to request an order number. Combination oral/nasal mask, used with continuous positive airway pressure device, each. Sleep. 4510 13th Ave. S. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 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. Version 2.6. Our site does not include the entire universe of available offers. 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. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. Review your policy to learn about the requirements specific to your insurance provider. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. 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. Sleep Res Online. Clin Chest Med. Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. References were updated. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). See the table below for the usual maximum amount of accessories considered to be medically necessary. 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. Available at: Kirk V, Baughn J, D'Andrea L, et al. 1997; 127(8 Pt 1):581-587. 2004; 130(1):58-66. 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. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. 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. Along with key review factors, this compensation may impact how and where products appear across the site (including, for example, the order in which they appear).