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. 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. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. According to theAmerican Academy of Sleep Medicine (AASM)obstructive sleep apnea (OSA) in adults is defined as either: Internal Medical Policy Committee 11-19-2020 Added Professional Statement and statement regarding cleaning devices, Internal Medical Policy Committee 9-21-2021 Coding update- Added new procedure code K1027, effective October 01, 2021. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. The Rationale, Definitions and References were updated. endobj 2001; 19(1):173-186. 1 0 obj This is a unique virtual learning experience for health care professionals caring for women and . 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. A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. 2009; 5(3):263-276. 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. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. Annals Intern Med. Blue Cross and Blue Shield Assoc. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h Medical policy list. Beginning November 1, 2020, we have a contracted network of dental providers with American Academy Dental Sleep Medicine (AADSM) certification to supply custom fitted sleep appliances (E0486) that are prescribed by a specialist in sleep disorders and authorized by our Utilization Management department according to the clinical guideline for coverage. Sleep Res Online. Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. Arch Dis Child. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance Rationale section was updated with information about acoustic pharyngometry and SNAP testing. American Academy of Pediatrics (AAP). Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. (such as sleep studies, CT scans) . Darien, IL: AASM; 2020. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. There are a number of optional accessories you can purchase for your CPAP machine. However, this information is provided without warranty. Littner M, Hirshkowitz M, Kramer M, et al. Additionally, nap sleep is not physiologically the same as nighttime sleep and does not adequately reflect the range of sleep phases required for proper diagnosis, therefore, results are not accurate when compared to the current standard of a full polysomnography (PSG). PAP devices may improve quality of life in individuals with sleep apnea in adults. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. Continued use beyond the first three (3) months of therapy. <> Ann Intern Med. Common warning signs include snoring and excessive daytime sleepiness (Kryger, 1997). Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. 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. PDF Blue Cross Blue Shield of Michigan Medical Policy Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome 2017; 13(10):1199-1203. This difference in efficacy is more pronounced for individuals with severe OSA, as oral appliances have been shown to be less efficacious in individuals with severe OSA than they are in individuals with mild-moderate OSA. 2004; 51(1):169-186. The medical records must also document objective findings of compliance information, (i.e. 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. Coverage | BlueCross BlueShield of South Carolina The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Marcus CL, Brooks LJ, Draper KA, et al. People with obstructive sleep apnea experience partial or complete closure of the upper airway during sleep, which can lead to snoring, gasping, or even choking. 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. 4510 13th Ave. S. 2017; 13(3):479504. Pediatr Clin North Am. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. All rights reserved. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. 2003; 87(4):803-833. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. Kryger MH. Dont forget to budget the ongoing costs of tubes, filters, and other replacements. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. 4 0 obj Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. However, youre probably wondering about insurance. So if youre close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. PDF 969 Sleep Disorder Management - Blue Cross Blue Shield of Massachusetts Chest. Involuntary sleepiness during activities that require little attention, such as watching TV or reading. Clin Chest Med. 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. 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. Fletcher EC, Stich J, Yang KL. Sleep. Respiratory polygraphy in sleep apnea diagnosis. Monahan KJ, Larkin EK, Rosen CL, et al. The cost you pay depends on your insurance coverage.In addition to the CPAP machine itself, you also need to pay for additional equipment such as filters, which run between $5 and $30, and masks, which can cost up to $100. Payment will be made for the purchase of the device whenBOTHof the following criteria are met: Throughout the PAP device rental period, the DME supplier must check that the member is compliant with use of the device. If you require more frequent replacements of certain components, those costs may be out of pocket. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. 2007; 3(7):737-747. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Payment may be made for one (1) appliance. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. The Eccovision Acoustic Reflection Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. Paying for your equipment directly gives you the opportunity to compare products and choose the CPAP equipment you find most suitable. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. The necessary doctors appointments and sleep studies come with their own costs, depending on your insurance plan and associated deductible. The medical records must also document objective findings of compliance information, (i.e. Risk factors for obstructive sleep apnea in adults. Your doctor must determine which type of study is right for you. Liners are not interfaces for use with a PAP mask. References and Coding were updated. ** Medical Management of Obstructive Sleep Apnea Syndrome See the table below for the usual maximum amount of accessories considered to be medically necessary. MPTAC review. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application Costs for purchasing a machine outright can range anywhere from $250 to $1,000 or more, depending on where you live and the type of machine you need. 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. Call the National Information Center at 1-800-411-BLUE (2583)weekdays from 8 a.m. to 8 p.m. Eastern time. References were updated. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Once you have the prescription, you can choose whether to buy your CPAP equipment outright or go through your insurance plan. A7027. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. Coverage continues if your sleep apnea improves with the CPAP treatment. No. 1 0 obj Positive Airway Pressure (PAP) Supplies - Regence Clinical practice. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. Not all insurance plans work the same way. J Clin Sleep Med, 2018; 14(7):1231-1237. 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. Hypertension Oct 1, 2020 Administrative. 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. 2002; 165(11):1499-1503. 2003; 26(6):754-760. Tubing with integrated heating element for use with positive airway pressure device, Combination oral/nasal mask, used with continuous positive airway pressure device, each, Oral cushion for combination oral/nasal mask, replacement only, each, Nasal pillows for combination oral/nasal mask, replacement only, pair, Full face mask used with positive airway pressure device, each, Face mask interface, replacement for full face mask, each, Cushion for use on nasal mask interface, replacement only, each, Pillow for use on nasal cannula type interface, replacement only, pair, Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap, Headgear used with positive airway pressure device, Chinstrap used with positive airway pressure device, Tubing used with positive airway pressure device, Filter, disposable, used with positive airway pressure device, Filter, non-disposable, used with positive airway pressure device, Oral interface used with positive airway pressure device, each, Exhalation port with or without swivel used with accessories for positive airway pressure devices, replacement only, Water chamber for humidifier, used with positive airway pressure device, replacement, each, **Allowing for a three (3) month supply *Allows for a 10 day delivery before run-out.
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October 2nd - 4th, 2020