blue cross blue shield sleep apnea coverage

When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. 1. Typically, you need a referral for a sleep study in order to receive coverage. 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. 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. Be sure to check your insurance policy to determine your specific requirements. 1997; 20(6):406-422. 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. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. JAMA. 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. The Rationale, Definitions and References have been updated. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. 3 0 obj PAP devices may improve quality of life in individuals with sleep apnea in adults. Insurance plans can significantly help defray the cost of a CPAP machine. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. Collop NA, Tracy SL, Kapur V, et al. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. 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. Front Psychiatry. According to the An American Sleep Disorders Association Report. The Ultimate Overview to Sleep Apnea with Effects, Therapy, Monitoring, Causes & Threat Factors Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance. Most insurance plans cover a portion of the cost of your sleep studies, including studies conducted in a sleep lab or at home. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. American Academy of Pediatrics (AAP). Medicare participants are responsible for paying their deductible, plus 20% of the machine rental. Sleep. Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life (QOL), productivity, and overall health. Pediatrics. 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". Additional appliances should be denied as not medically necessary. Blue Cross Blue Shield North Carolina does cover weight loss surgery, but your specific policy must include it in order for you get it covered. American Sleep Disorders Association and Sleep Research Society. The document header wording was updated from Current Effective Date to Publish Date. References were updated. Olejniczak PW, Fisch BJ. Replacement of PAP Devices 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. A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Other criteria are unchanged for MSLT and other services. Sleep Diag Ther. 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. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. If you fail to meet these requirements, you have to begin the process again. Pediatr Clin North Am. PAP (positive airway pressure) Machines and Humidifiers, Typically, filter replacements are every 30 days, Typically, tubing replacements are every 3 months, Typically, mask replacements are every 3 months, 3-month rental, 4th-month purchase (many PPO insurances), 10-month rental (most HMO insurance and some PPO insurances), 13-month rental (Medicare and other government insurance). A trial with CPAP has failed or is contraindicated; The device is prescribed by a treating physician; The device is custom-fitted by qualified dental personnel; There is absence of temporomandibular dysfunction or periodontal disease. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. References were updated. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. 2007; 146(3):157-166. The medical records must also document objective findings of compliance information, (i.e. Sleep. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. 4 0 obj 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. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. <> Available at: Journal of the American Medical Association. % Thanks for the feedback - we're glad you found our work instructive! Swiss Med Wkly. 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- 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. 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. Sleep Res Online. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. 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. 2009; 5(3):263-276. 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. 2000; 3(4):169-172. Blue Cross and Blue Shield Assoc. Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. (such as sleep studies, CT scans) . Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. %PDF-1.7 Marino M, Li Y, Rueschman MN, et al. Want to read more about all our experts in the field? Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. Available at: Thurnheer R, Bloch KE, Laube I, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. No other changes were made to statements or criteria. Clin Chest Med. <> American Academy of Sleep Medicine (AASM). Keep in mind that whether or not you use insurance, medical equipment sellers require a CPAP prescription in order for you to purchase the machine and equipment. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. 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. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 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. Ann Intern Med. July 15, 2018. When you buy through our links, we may earn a commission. Take the Sleep Quiz to help inform your sleep improvement journey. 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). Involuntary sleepiness during activities that require little attention, such as watching TV or reading. ; Swiss Respiratory Polygraphy Registry. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. 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). Effective April 01, 2023. Sleep. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Available at. 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. Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. 1997; 127(8 Pt 1):581-587. Save my name, email, and website in this browser for the next time I comment. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Updated the formatting of the Position Statement section. eligible for coverage. 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. PAP devices have directions from the manufacturing company included for cleaning. Young T, Skatrud J, Peppard PE. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. 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. 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. SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 You might be able to find direct-to-supplier CPAP manufacturers with lower prices than those available through your insurance plan, though be sure to check if these devices are approved by the FDA. More than 75% of the apneas or hypopneas must have an obstructive pattern. Available at: Berry RB, Quan SF, Abreu AR, et al. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . AHRQ Technology Assessment Program. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. This means your doctor still needs to conduct a sleep study to give you a diagnosis. 2002; 347(7):498-504. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. Sleep. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. Kryger MH. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. 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. 2 0 obj If you require more frequent replacements of certain components, those costs may be out of pocket. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. References and Coding sections were also updated. A7027. 3 0 obj There is additionally a vital hereditary component to the disease. While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. The medical records must also document objective findings of compliance information, (i.e. These are not considered 'interfaces' as defined in this policy. CPT Only - American Medical Association, https://jcsm.aasm.org/doi/10.5664/jcsm.7230, https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&, http://aasmnet.org/Resources/PracticeParameters/Outofcenter.pdf, http://jcsm.aasm.org/ViewAbstract.aspx?pid=30972, http://pediatrics.aappublications.org/content/130/3/576.full.pdf+html, https://aasm.org/aasm-introduces-new-patient-education-website-sleepeducation-com/, http://jama.ama-assn.org/cgi/reprint/285/22/2936?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=Patient+page%3A++Breathing+problems+during+sleep&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.

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