Guidelines are designed to support the decision-making processes in patient care. Home/Portable sleep study (may also be known as NightWatch System, AutoSet Recorder, Morpheus System): A diagnostic test proposed for home use which may be self-administered or attended by a technician. <> The effective date is February 26, 2018. Effective April 01, 2023. Available at. 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). dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. 2008; 162(4):350-358. J Clin Sleep Med. Version 2.6. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. 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. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. MPTAC review. The Rationale, Definitions and References were updated. The machine attaches to a mask that you wear over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open. Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. 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. PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. 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) and. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. Mysliwiec V, Martin JL, Ulmer CS, et al. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. Following are a list of Blue Cross Blue Shield North Carolina plan types and whether they cover bariatric surgery: Weight Loss Surgery for Health Plans Through Your Work MPTAC review. Home diagnosis of sleep apnea: a systematic review of the literature. 3 months/90 days. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Most insurance will not cover the following categories of products: - Cleaning Supplies: So Clean CPAP Sanitizer, Mask Wipes, etc. The indications for polysomnography and related procedures. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. BOTH Seen as youll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. 2 0 obj Available at: Thurnheer R, Bloch KE, Laube I, et al. 2017; 13(10):1199-1203. 2004; 8(3):611-630. The Definitions and References were updated. 2007; 3(7):737-747. NCD #240.4.1. 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. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. 2003, 26(7):907-913. MPTAC review. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- He has tested hundreds of mattresses and sleep products. Other criteria are unchanged for MSLT and other services. How Often Does Insurance Cover a New CPAP Machine? Obtain an order number Login or register with Carelon's ProviderPortal Phone 1 (877) 291-0509 References and Coding sections were also updated. <> 2004; 51(1):169-186. These coverage types are separate from one another. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Payment may be made for one (1) appliance. American Academy of Sleep Medicine; Standards of Practice Committee. Swiss Med Wkly. Oxygen saturation measures the significance of respiratory events. ** Medical Management of Obstructive Sleep Apnea Syndrome Netzer NC, Stoohs RA, Netzer CM, et al. Liners are not interfaces for use with a PAP mask. While the use of actigraphy has been demonstrated to be useful in the detection of sleep problems in healthy or normal individuals, potential benefits for individuals with suspected sleep disorders have not been shown. 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. The machine is returned to the doctor the following morning for data analysis. 1996; 11(2). Chest. Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. Clinical Practice Guidelines | Blue Cross and Blue Shield of Illinois So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. 2007; 30(4):519-529. Editorial opinions expressed on the site are strictly our own and are not provided, endorsed, or approved by advertisers. %PDF-1.7 Recommendations from other national entities may vary. 2002; 347(7):498-504. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. 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. 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. Coverage | BlueCross BlueShield of South Carolina Other insurance providers may have different standards. 4510 13th Ave. S. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: The following codes for treatments and procedures applicable to this document are included below for informational purposes. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. CPAP therapy is effective, but it can also be expensive. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. Your plan may include different types of coverage, such as for health and dental. is found to be more effective in the sleep lab to be . Click the button below to request a free, no-obligation verification. 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. Close follow-up for PAP device usage and problems in individuals with sleep apnea by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems if needed. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . Your AHI must also meet the same requirements as for Medicare: If you meet these requirements, then Medicaid provides CPAP coverage for a 12-week trial. Polysomnography (PSG) also typically includes electrocardiography and monitoring of Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Levenson JC, Troxel WM, Begley A, et al. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Practice Parameters for the Indications for Polysomnography and Related Procedures. Our site does not include the entire universe of available offers. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). Sleep disorder: A disruptive pattern of sleep that may include difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep. - Any additional medical records, such as your sleep study, that your insurance company requests. 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. However, this information is provided without warranty. 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. Fargo, N.D., 58121. Pediatrics. 2000; 3(4):169-172. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. The technique is based on the analysis of sound waves that are launched from a loudspeaker and travel along a wave tube into the subjects airways where they are reflected. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. Be aware that if you decide to stop CPAP treatment and decide later that you want to try the treatment again, your insurance company may require you to re-qualify for coverage. 2007; 137(5-6):97-102. Extended! Free CME credits for Training On Bias in Maternal Health m|(=IPYAcmAa#nhwRz(v^6;Ut4?o+UIv(($HSnG>:~;khOFtUG+'@Gq^B0kT$Ae/a#*lJk=aZdj~\:POhI-y p;6p=E?t:M?h=U,>) ]1r!!pr8lDbDadJJV|p6l-Dq. A liner used in conjunction with a PAP mask is considered a comfort and convenience item and is considered a non-covered item or service. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. 2020; 172(5):325-336. 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. 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. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. 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. References were updated. 1. Airflow and respiratory effort in conjunction with oxygen saturation: These terms are translated into the standard measures of apneic-hypopneic index (AHI) or respiratory disturbance index (RDI). 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. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. 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.
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