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. State of South Carolina - Coverage Information You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. MPTAC review. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. Devices Used for the Treatment of Sleep Apnea in Adults Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Clinical practice. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. 2019; 46:151-160. 1 0 obj The policy is available on our website, www.bluecrossnc.com, for your reference and will reflect the changes noted below by April 1. The Definitions and References were updated. Unattended home diagnosis and treatment of obstructive sleep apnea without polysomnography. Your daily habits and environment can significantly impact the quality of your sleep. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. MPTAC review. Shift work sleep disorder (SWSD): A sleep disorder that is related to unusual or constantly changing work schedules and results in symptoms of insomnia or excessive sleepiness. 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. Updated Coding section with 01/01/2010 CPT changes. Chest. Yes! 2020; 172(5):325-336. 2004; 8(3):611-630. Olejniczak PW, Fisch BJ. 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. PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL Nap study: This term refers to a shorter daytime version of a PSG sleep study. 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. Blue Cross Blue Shield of Massachusetts has delegated utilization management to AIM Specialty Health (AIM) for Sleep Disorder Management. Strollo PJ Jr. On the other hand, if you have a co-insurance plan, you will also be billed monthly for the rental cost of the device, alongside your insurance company. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. More than 75% of the apneas or hypopneas must have an obstructive pattern. Effective March 3, 2009. Front Psychiatry. Our site receives compensation from many of the offers listed on the site. 4 0 obj See the table below for the usual maximum amount of accessories considered to be medically necessary. Clin Chest Med. Collop NA, Tracy SL, Kapur V, 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. Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. Apnea: A transient period where breathing ceases. It happens when the muscles in the throat relax and block the air passages to make sure . Information on this website should not be construed as medical advice. PDF Blue Cross Blue Shield of Michigan Medical Policy Watanabe T, Kumano-Go T, Suganuma N, et al. endobj Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: Danny is a Certified Sleep Science Coach with an in-depth knowledge of sleep health. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. endobj There is no additional payment for liners used with a PAP mask. Note: 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. Centers for Medicare and Medicaid Services. The criteria for home portable monitors/sleep testing have been removed from this document and placed in CG-MED-01 Polysomnography and Home Portable Monitors. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Darien, IL: AASM; 2020. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Involuntary sleepiness during activities that require some attention, such as meetings or presentations. 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. ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . 2004; 291(16):2013-2016. 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. The content on this website is for informational purposes only. Rationale section was updated with information about acoustic pharyngometry and SNAP testing. Want to read more about all our experts in the field? This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. The machine is returned to the doctor the following morning for data analysis. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Medical policy list | Blue Shield of CA Provider Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). Pediatr Clin North Am. J Clin Sleep Med. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. Smith MM, McCrae CC, Cheung JJ, et al. Some rental plans may include the cost of replacement equipment, which is something to bear in mind when comparing the cost of buying outright versus going with insurance. 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. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. 3 months/90 days. Home diagnosis of sleep apnea: a systematic review of the literature. 3 0 obj The use of specific product names is illustrative only. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. Technology Evaluation Center (TEC) assessments. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. Levenson JC, Troxel WM, Begley A, et al. Kryger MH. 4510 13th Ave. S. 2003; 124(4):1543-1579. 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. Guilleminault C, Abad VC. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. Practice Parameters for the Indications for Polysomnography and Related Procedures. 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. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h MPTAC review. Note: CPAP has been shown to have greater effectiveness than oral appliances in general. 2000; 3(4):169-172. J Sleep Res. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface. PDF FEP Medical Policy Manual According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 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 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. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Littner M, Hirshkowitz M, Kramer M, et al. Mysliwiec V, Martin JL, Ulmer CS, et al. Filters, which need to be replaced frequently, run between $5 and $30 each. An AHI between 5 and 15 is considered mild, an AHI between 15 and 30 is moderate, and an AHI greater than 30 is severe. Some providers reimburse you for the cost of purchasing the machine outright, while others require a rent-to-own plan under which you must use the machine for a set amount of time before it becomes your property. 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. 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 . Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. Before making a final decision, please read the Plan's federal brochure (RI 71-005). Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance 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. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). 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. Mulgrew AT, Fox N, Ayas NT, Ryan CF. 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. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe References were updated. 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. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. Indications for treatment of obstructive sleep apnea in adults. Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. PDF FEP Medical Policy Manual - FEP Blue Morgenthaler TI, Aurora RN, Brown T, et al. MPTAC review. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. 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). 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. J Clin Sleep Med. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. 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. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. Respicardia Announces Highmark Coverage for the rem Over-the-counter (OTC) or prefabricated intra-oral appliances to treat OSA are not considered to be appropriate therapy for OSA in any clinical situation and, therefore, are non-covered.
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