2001; 285(22):2936. When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Episodes often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. 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. If the CPAP therapy helps improve your sleep apnea symptoms during the 12-week period, Medicare continues to cover the cost of your CPAP equipment. - Blue Cross and Blue Shield's Federal Employee Program Then there are supplies that need to be replaced over time, including: The costs for each component vary. Sleep Apnea Diagnosis and Medical Management - Blue Cross NC Front Psychiatry. CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Well answer some of the most commonly asked questions about CPAP machines, equipment, and insurance coverage. He has tested hundreds of mattresses and sleep products. Upper airway: The area of the upper respiratory system including the nose, mouth and throat. 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. Treatment of Obstructive Sleep Apnea Procedure code: E0601 Background: Sleep Apnea Sleep apnea occurs when an adult stops breathing or has slowed breathing during sleep. 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. 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. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. 1 0 obj Sleep. OPT devices (e.g., Winx Sleep Therapy System) are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. Fargo, N.D., 58121. Sleep. Obstructive sleep apnea syndromes. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009). Efforts are made to maintain reliable data on all information presented. <> 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. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. American Academy of Sleep Medicine; Standards of Practice Committee. % Westchester, IL: American Academy of Sleep Medicine; 2007. Thanks for the feedback - we're glad you found our work instructive! The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." The medical records must also document objective findings of compliance information, (i.e. Oct 1, 2020 Administrative. Kapur VK, Auckley DH, Chowdhuri S, et al. 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. Click the button below to request a free, no-obligation verification. PDF Medical Management of Obstructive Sleep Apnea Syndrome - Blue Cross and 1997; 20(6):423-487. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . Devices Used for the Treatment of Sleep Apnea in Adults Get timely provider information including policy, benefits, coding or billing updates, education, and moredelivered directly to your email. Patient Page. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Daytime electrical stimulation (eXciteOSA) of the tongue is considered experimental/investigation and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-review literature. SleepFoundation.org does not provide medical advice, diagnosis, or treatment options. The use of specific product names is illustrative only. 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. Arch Pediatr Adolesc Med. 2003, 24(2):307-313. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. 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. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. 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 A7027. 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. E 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. These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . If you require more frequent replacements of certain components, those costs may be out of pocket. There are a number of optional accessories you can purchase for your CPAP machine. 2021 cpaphackers.com | All rights reserved. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Apnea: A transient period where breathing ceases. Netzer NC, Stoohs RA, Netzer CM, et al. 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). Bi-level Positive Airway Pressure(BiPAP) without back-up rate. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. BiPAP machines, which provide a different level of air pressure for exhalation and inhalation, frequently run in the thousands of dollars. endobj Excessive daytime sleepiness: This refers to a condition where a person feels very drowsy during the day, even after getting adequate nighttime rest, and has a tendency to fall asleep or requires extra effort to avoid sleeping in inappropriate situations, such as at work or driving. Dise Is A Prerequisite To Inspire Blue Cross Blue Shield North Carolina does cover weight loss surgery, but your specific policy must include it in order for you get it covered. Sleep apnea is a harmful condition that can have substantial negative impacts on health. Covered sleep apnea Diagnosis Codes for procedure code E0601, Non-Covered Diagnosis Codes for procedure code E0471. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. An AHI between 5 and 15 is considered mild, an AHI between 15 and 30 is moderate, and an AHI greater than 30 is severe. 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. Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. 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. 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. Blue Cross Sleep Apnea Coverage - HealthySleepClub.com Many insurance providers use the Medicare guidelines for replacing equipment: However, each provider has its own replacement guidelines. endobj Med Clin North Am. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. x%xuY2dpVcE/@ah7F]UdjEfd?GD?gg_|?\g_vwV.{5Zn||6H3htwME#r7KG=.w.LrGK!gC$Z:UwcrYAR#Oc1e w|nl8.4qg2JAS]z7=H#{AYkt=C^zEg1fn). Obesity is defined as a BMI greater than the 90th percentile for the weight/height ratio. 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. Ann Intern Med. However, youre probably wondering about insurance. First, your doctor must diagnose you with obstructive sleep apnea following an approved laboratory sleep study or an at-home sleep study, and give you a prescription for a CPAP machine. Oxygen saturation measures the significance of respiratory events. Home diagnosis of sleep apnea: a systematic review of the literature. risk of central sleep apnea, (chronic use defined as use of opioids on most days per week for greater than 3 months) Obesity hypoventilation syndrome, defined as pCO 2 greater than 45 mm Hg and pO 2 less than 60 mm Hg on arterial blood gas. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. %PDF-1.7 Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. 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 The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> <> Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. If youre among the 2% to 9% of adults who suffer from obstructive sleep apnea, a CPAP machine may be the solution to better sleep. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone (PAT), oximetry and actigraphy may be considered Sleep. Only 10% allow for more frequent replacement. Removed ICD-9 codes from Coding section. Masks often cost $100 or more, and other equipment ranges between $20 and $100. American Academy of Sleep Medicine (AASM). Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Our site does not include the entire universe of available offers.