Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. This revised Medical Policy will apply to both professional provider and facility claims. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. Sleep education. If you're ready for more, sign up to receive our email newsletter! PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage More than 75 percent of the apneas or hypopneas must have an obstructive pattern. However, the utility of acoustic pharyngometry measurement in the clinical setting of OSA has not been demonstrated, and it remains unclear how this test will impact treatment planning and clinical outcomes. It happens when the muscles in the throat relax and block the air passages to make sure . Involuntary sleepiness during activities that require more active attention, such as talking or driving. Act now to earn free CME credits and helps advance maternal health in New Jersey. American Academy of Sleep Medicine (AASM) Updates to Sleep Apnea Corporate Medical Policy - Blue Cross NC Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. . 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. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. 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. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a CPAP machine. Coverage continues if your sleep apnea improves with the CPAP treatment. NCD #240.4.1. Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; The individual is experiencing success in treatment. 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. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. Devices Used for the Treatment of Sleep Apnea in Adults This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. American Academy of Sleep Medicine; Standards of Practice Committee. 2001; 285(22):2936. 2010; 95(12):1031-1033. Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based PSG or with a positive home/portable sleep test); AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual. N Engl J Med. 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. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. 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. However, youre probably wondering about insurance. MPTAC review. Not sure what your Blue Cross insurance covers? 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. 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. Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnea, as long as you meet the following requirements: You must also meet Medicares compliance requirements, which state that you must use the machine at least 4 hours per night, 70% of the time or more, during the first 3 months. Everyone's insurance plan is different. State Medicaid programs typically follow the same guidelines as Medicare. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. 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. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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). - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). 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. Indications for treatment of obstructive sleep apnea in adults. Am J Respir Crit Care Med. J Clin Sleep Med. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. J Sleep Res. Blue Care Network's medical policy on the diagnosis and management of obstructive sleep apnea includes coverage for home sleep studies for members with symptoms of OSA without other comorbid conditions. Your plan may include different types of coverage, such as for health and dental. 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. 2004; 291(16):2013-2016. 2019; 46:151-160. %PDF-1.7 2007; 1:1-8. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. Young T, Skatrud J, Peppard PE. Fletcher EC, Stich J, Yang KL. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. 4 0 obj More advanced machines tend to cost more. 1997; 20(6):406-422. 2017; 13(3):479504. In order to prove your eligibility for coverage of your CPAP device, Anthem Blue Cross will require documentation such as relevant doctors notes, sleep test results, a prescription, and may include other documents, too. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. Technology Evaluation Center (TEC) assessments. This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Trikalinos TA, Ip S, Raman G, et al. 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. J Clin Sleep Med. There are a number of optional accessories you can purchase for your CPAP machine. Medical policy list | Blue Shield of CA Provider Marino M, Li Y, Rueschman MN, et al. These coverage types are separate from one another. Efforts are made to maintain reliable data on all information presented. 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 major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. O'Driscoll DM, Foster AM, Davey MJ, et al. Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Combination oral/nasal mask, used with continuous positive airway pressure device, each. Well cover some of the most common insurance policies surrounding CPAP equipment. Available at. State of South Carolina - Coverage Information