Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. All rights reserved. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. 1. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity. 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). 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. 2.01.18 Diagnosis of Obstructive Sleep Apnea Syndrome - Blue Shield of 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. Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements. 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- Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Portable Monitoring Task Force of the American Academy of Sleep Medicine. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. American Academy of Sleep Medicine (AASM). Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. 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. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. BCBSNC will provide coverage for Diagnosis and Medical Management of Sleep Apnea when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. 2004; 8(3):611-630. Want to read more about all our experts in the field? for the American Academy of Sleep Medicine. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. Other criteria are unchanged for MSLT and other services. 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. Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). July 15, 2018. J Clin Sleep Med. Payment may be made for one (1) appliance. - Blue Cross and Blue Shield's Federal Employee Program 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". <> 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. First, you must have a prescription for CPAP therapy from your healthcare provider. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. Sleep. Liners are not interfaces for use with a PAP mask. MPTAC review. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. 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. CPAP therapy is effective, but it can also be expensive. Starting January 1, 2018, AIM Specialty Health (AIM) will conduct clinical reviews for all sleep studies on behalf of Premera. 2000; 9(2):168-174. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. The content on this website is for informational purposes only. Most insurance plans partially cover the costs of CPAP machines and related equipment. Efforts are made to maintain reliable data on all information presented. Netzer NC, Stoohs RA, Netzer CM, et al. BCBS of Kansas, which covers approximately 560,000 members.. When purchasing with an insurance provider, you are restricted to the suppliers that are covered by your insurance. Practice parameters for using polysomnography to evaluate insomnia: an update. 1999; 131(7):485-491. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. Inspire Medical wins more Blue Cross Blue Shield coverage 2007; 16(2):213-216. A position statement regarding MWT was added. Policy Statement . These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . %PDF-1.7 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 Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. 2004; 291(16):2013-2016. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 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. O'Driscoll DM, Foster AM, Davey MJ, et al. Blue Cross Sleep Apnea Coverage - HealthySleepClub.com The members contract benefits in effect on the date that services are rendered must be used. x\Ys~W5p8krxv~qL 4@q_y)N&Bee\>U?0fxywC]|59wo_^UQ^C?^x"/0>_|}yiEQ$5U+/_'~M*yIaaT)GT=r4K%8K^VAfy?WC}l[6~;pklytDRRUAXH,{["GowQmU^VqU0V3,0m0O~d]y Im{W(x9AdWq &KaFgE/ +S/`5UeW'~S#s_jsE;kym+//}1M'x Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. An AHI/RDI greater than 30 is consistent with severe OSA. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). ffective April 01, 2022, Internal Medical Policy Committee 3-23-2023 Coding update - Children frequently exhibit behavioral problems or hyperactivity rather thandaytime sleepiness. 2003; 87(4):803-833. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy. Everyone's insurance plan is different. 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. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. Medically necessary criteria regarding Type III home portable devices were updated with information about newer models of the SNAP devices that are considered Type III devices. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. J Clin Sleep Med. Required fields are marked *. There is no additional payment for liners used with a PAP mask. 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). Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 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. Obstructive sleep apnea syndromes. Available at: Journal of the American Medical Association. 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. After reading and interpreting the results of your sleep study, your doctor may diagnose you with sleep apnea and work with you to develop a treatment plan. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. Does Insurance Cover CPAP Machines and Supplies? | Sleep Foundation Types of coverage. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Sleep Apnea. ; Swiss Respiratory Polygraphy Registry. Inspire Medical wins coverage from five more BCBS plans Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- 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. J Sleep Res. 2005; 128(4):2166-2175. PDF Medical Policy - Sleep Disorders, Diagnosis and Medical Management Sleep Medicine - Regence Your AHI is the average number of partial or complete breathing cessation events you experience per hour. APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA. Not sure what your Blue Cross insurance covers? 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. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. It isnot intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. This condition is associated with frequent awakening and often with daytime sleepiness. Pediatrics. Oct 1, 2020 Administrative. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. Please reference the Sleep Disorder Management order entry worksheets before submitting your request. 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. 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.

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