Masks often cost $100 or more, and other equipment ranges between $20 and $100. Most CPAP machines cost between $500 and $800. MPTAC review. 3 0 obj 1997; 20(12):1208. 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. Tubing with integrated heating element for use with positive airway pressure device. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. 2008; 31(1):141-147. Available at: Thurnheer R, Bloch KE, Laube I, et al. A provider's office can often get an immediate approval when they submit a request online. Updated Coding section with 01/01/2010 CPT changes. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Arch Pediatr Adolesc Med. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale. Arch Dis Child. Measurements usually involve the detection of wrist movements. Not all insurance plans work the same way. How Often Does Insurance Cover a New CPAP Machine? American Sleep Disorders Association and Sleep Research Society. American Academy of Sleep Medicine. 1996; 11(2). PDF 969 Sleep Disorder Management - Blue Cross Blue Shield of Massachusetts Hypertension Programs and resources to help you prevent and manage hypertension. Payment may be made for one (1) appliance. Doctors can test for sleep apnea with an overnight in-lab sleep study, also called a polysomnography, or with an at-home sleep study. If the device isnt being used as prescribed, the DME supplier should contact the individuals physician and discuss removal of the device. 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. 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. Blue Shield of California (BSC) requires an unattended (unsupervised) home sleep apnea test (HSAT) The following diagnostic tests are considered investigational and not medically necessary: The evidence in the medical literature does not support the use of single nap studies. No change to criteria except for the addition of or to the medically necessary indications for MSLT in place of the and for clarification. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. You must decide if you prefer to pay the full cost of the monthly rental, purchase the machine outright, or stop CPAP treatment altogether. J Sleep Res. 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 type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. - Blue Cross and Blue Shield's Federal Employee Program Version 2.6. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. <> Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Updated Coding section with 01/01/2011 CPT changes; removed 0203T, 0204T deleted 12/31/2010. 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. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. Revisions also made to Coding section for clarification of MWT coding. D'Andrea LA. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Medical Management of Obstructive Sleep Apnea Syndrome Policy # 00328 Original Effective Date: 07/27/2012 Current Effective Date: 01/09/2023 2022 Blue Cross and Blue Shield of Louisiana . Note: Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. JAMA. Am J Respir Crit Care Med. - Your signed Assignment of Benefits Agreement, which allows us to accept payment for the equipment from your insurance. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM). BlueCHiP for Medicare and Commercial Intraoral appliances for use in the treatment of documented mild to moderate obstructive sleep apnea are covered under the member's durable medical equipment service. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." 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- More than 75 percent of the apneas or hypopneas must have an obstructive pattern. Guidelines are designed to support the decision-making processes in patient care. More expensive accessories often come with warranties of 1 to 3 years. Continued use beyond the first three (3) months of therapy PDF FEP Medical Policy Manual MPTAC review. Medical policy list | Blue Shield of CA Provider 2002; 165(11):1499-1503. These include: Insurance does not typically cover any products that are considered optional. PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage Your doctor must determine which type of study is right for you. Your daily habits and environment can significantly impact the quality of your sleep. endobj 2003, 24(2):307-313. Front Psychiatry. stream FEP Basic Option Plan Benefits Chart - Blue Cross and Blue Shield's As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. 1 0 obj Chest. Updates to Sleep Apnea Corporate Medical Policy - Blue Cross NC Marcus CL, Brooks LJ, Draper KA, et al. For general information about AIM Specialty Health, call 1-847-564-8500, Monday through Friday, from 9 a.m. to 6 p.m., Eastern Time (ET). These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation. Netzer NC, Stoohs RA, Netzer CM, et al. Nasal EPAP devices (e.g., Provent, Theravent) 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. Standards of Practice Committee of the American Sleep Disorders Association. Title was revised to remove MSLT and retitle: Selected Sleep Testing Services. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. References and Coding sections were also updated. Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Collop NA, Tracy SL, Kapur V, et al. 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. See the table below for the usual maximum amount of accessories considered to be medically necessary. Available at: Epstein LJ, Kristo D, Strollo PJ, et al. When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, both now and in the long run. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Once youre prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. Home sleep studies are covered to diagnose obstructive sleep apnea for members who fit the following description: Medical Policy & Technology Assessment Committee (MPTAC) review. Note:See the table below for the usual maximum amount of accessories considered to be medically necessary. Document was revised to remove statements about MSLT and MWT which are now addressed in separate CG-MED-43. Narcolepsy: This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy). 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. References were updated. Swiss Med Wkly. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service. Respiratory polygraphy in sleep apnea diagnosis. The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009).
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