blue cross blue shield sleep apnea coverage

• 8 September 2023

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. 1997; 20(6):423-487. Flemons WW, Littner MR, Rowley JA, et al. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . Home diagnosis of sleep apnea: a systematic review of the literature. (such as sleep studies, CT scans) . 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. 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. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. July 15, 2018. Most machines record your use for you. Updated Coding section with 01/01/2010 CPT changes. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the individual may be switched to BiPAP; For whom BiPAP is found to be more effective in the sleep lab. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. 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. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. 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. Med Clin North Am. Inspire Medical wins more Blue Cross Blue Shield coverage In order to buy a CPAP machine, you must have results from a sleep study and a CPAP prescription from your doctor or healthcare professional. Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. Your doctor will first check for symptoms of obstructive sleep apnea, including: If your symptoms indicate you might have obstructive sleep apnea, the next step is to take a sleep study. Trikalinos TA, Ip S, Raman G, et al. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. %PDF-1.7 Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. 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 . Ann Intern Med. BOTH According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. MPTAC review. 2013; 9(2):125-131. 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. Risk factors for obstructive sleep apnea in adults. Most insurance plans offer partial coverage for CPAP machines once you meet your deductible. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. Your plan may include different types of coverage, such as for health and dental. 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. Chesson AL Jr, Ferber RA, Fry JM, et al. Everyone's insurance plan is different. Sleep-disordered breathing (SDB): A term for abnormalities of respiration during sleep. 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. PDF FEP Medical Policy Manual - FEP Blue Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness. SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. 1 0 obj The document header wording was updated from Current Effective Date to Publish Date. References were updated. No other changes were made to statements or criteria. Guilleminault C, Abad VC. 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. Watanabe T, Kumano-Go T, Suganuma N, et al. The Rationale, Definitions and References have been updated. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. Medical policy list | Blue Shield of CA Provider Dise Is A Prerequisite To Inspire More than 75 percent of the apneas or hypopneas must have an obstructive pattern. More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). American Academy of Pediatrics (AAP). Available at: Thurnheer R, Bloch KE, Laube I, et al. Respiratory polygraphy in sleep apnea diagnosis. In order to be eligible for reimbursement, The Centers for Medicaid and Medicare (CMS) require proof that you are using the CPAP machine at least 4 hours per night, on 70% of nights, in a consecutive 30-day period. There is additionally a vital hereditary component to the disease. Updated coding: Added CPT code 95806 and 0089T; removed CPT codes 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145, 95806, 95808, 95810, 95811, 99508; removed ICD-9 Procedure codes 76.62, 76.63, 76.64, 76.65, 76.66, 89.17; removed HCPCS codes E0561, E0562, E0601, K0183, K0189, K0268, K0531, K0532, K0533, S8260, D7940, D7944, D7946, D7947, D7948, D7949, D7950, D7950, D7995, D7996, S2080, 0088T. 2004; 8(3):611-630. Marino M, Li Y, Rueschman MN, et al. 2019; 10:551. Chest. Centers for Medicare and Medicaid Services. Act now to earn free CME credits and helps advance maternal health in New Jersey. This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. - Any additional medical records, such as your sleep study, that your insurance company requests. Updates to Sleep Apnea Corporate Medical Policy - Blue Cross NC Your coverage which services your plan helps pay for and how the payment structure works depends on the terms of your specific plan. Fletcher EC, Stich J, Yang KL. If youre considering starting CPAP therapy, you may be wondering whether you can offset part of this cost with your insurance plan. <> CPAP machine prices start around $250 and can reach $1000 or higher. The Definitions and References were updated. 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. Townsend D, Sharma A, Brauer E, et al. MPTAC review. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. - Blue Cross and Blue Shield's Federal Employee Program If you're ready for more, sign up to receive our email newsletter! Sleep Medicine - Regence This revised Medical Policy will apply to both professional provider and facility claims. Once the 13 months have passed, you own the machine. Sleep. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Your doctor must determine which type of study is right for you. An American Sleep Disorders Association Report. 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. 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 2007; 16(2):213-216. MPTAC review. BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. PDF 969 Sleep Disorder Management - Blue Cross Blue Shield of Massachusetts Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome <>/Metadata 259 0 R/ViewerPreferences 260 0 R>> endobj You must also adhere to the same compliance requirements as Medicare recipients, namely using the machine at least 4 hours every night on 70% of nights. References and Coding sections were also updated. Devices Used for the Treatment of Sleep Apnea in Adults Nap study: This term refers to a shorter daytime version of a PSG sleep study. 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. Sleep Diag Ther. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. 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. Controversies in sleep medicine: terminology and definitions in sleep-disordered breathing.

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