Sleep. Apnea-Hypopnea index (AHI) or Respiratory disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. 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. Blue Cross and Blue Shield Kansas is an independent licensee of the Blue Cross Blue Shield Association Contains Public Information Populations Interventions Comparators Outcomes Individuals: With suspected obstructive sleep apnea Interventions of interest are: Limited channel home sleep apnea testing Comparators of interest are: This eliminates the possibility of needing to return your machine and restart the process of getting a sleep test and prescription from your doctor. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. There are many different types of sleep-related disorders, including obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), insomnia, narcolepsy, nocturnal movement disorders, such as Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD), unexplained excessive daytime sleepiness, and arousal disorders (parasomnias). Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. 2001; 285(22):2936. J Sleep Res. A provider's office can often get an immediate approval when they submit a request online. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. endobj 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. Dise Is A Prerequisite To Inspire 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. To determine your AHI, you must undergo a sleep study in a sleep lab or at home using at-home testing equipment. 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. First, you must have a prescription for CPAP therapy from your healthcare provider. 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). The medical records must also document objective findings of compliance information, (i.e. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. Our site does not include the entire universe of available offers. If you have any questions about the guidelines, or wish to provide feedback, this can be done by contacting the Quality Improvement Department at 312-653-3465. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information. Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life (QOL), productivity, and overall health. References were updated. Typically, you need a referral for a sleep study in order to receive coverage. Masks often cost $100 or more, and other equipment ranges between $20 and $100. CSA results from the brain's inability to send appropriate signals to the respiratory muscles to stimulate breathing. The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. 1997; 20(6):423-487. Ann Intern Med. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Pediatrics. 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". Many insurance providers require you to meet your annual deductible before covering your CPAP equipment. 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. stream Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. 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. Benefits Application This medical policy relates only to the services or supplies described herein. American Academy of Sleep Medicine (AASM). Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. 3 0 obj Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Five more Blue Cross Blue Shield health plans have extended coverage to Inspire Medical Systems' (NYSE: INSP) sleep apnea therapy, the company said today. Levenson JC, Troxel WM, Begley A, et al. Blue Cross and Blue Shield Assoc. It happens when the muscles in the throat relax and block the air passages to make sure . Available at. Removed ICD-9 codes from Coding section. 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. Guilleminault C, Abad VC. Mysliwiec V, Martin JL, Ulmer CS, et al. Sleep. Front Psychiatry. Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels. Most insurance plans partially cover the costs of CPAP machines and related equipment. Another type of sleep disturbance is simply known as apnea or central apnea. This condition, caused by problems in the central nervous system, is unrelated to OSA and is not addressed in this document. J Clin Sleep Med. According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. 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. If you require more frequent replacements of certain components, those costs may be out of pocket. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Clinical practice. Typical CPAP device prices range from $250 to $1000 or more, not including the cost of necessary accessories such as filters and masks. 3 months/90 days. Neurol Clin. Insurance plans can significantly help defray the cost of a CPAP machine. Therefore, it is particularly important that individuals with severe OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance. @f4=:B5vq1=^- J)l5K7LH8|E6 1cqtEK=-!MHpIi%|2Qx#$:bDSX(3Q.q3U~23t{4>g>'Gd?qqQzbc>y>(q[@=r5"&'IVQBp3L.U5COHUHd"1xqz##{h 2019; 46:151-160. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. The reason for this is that CPAP devices are a class II medical device under FDA regulation, meaning you require a prescription in order to obtain one, and in order to get the prescription, you need to undergo a sleep study and have a board-certified sleep specialist physician interpret your results and prescribe CPAP treatment before you undergo CPAP therapy. However, if the member is found to be using the PAP device as directed and is achieving the desired results, the DME supplier must contact the individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. 2010; 95(12):1031-1033. Your plan may include different types of coverage, such as for health and dental. 3 months/90 days. 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). Over-the-counter (OTC) or prefabricated intra-oral appliances to treat OSA are not considered to be appropriate therapy for OSA in any clinical situation and, therefore, are non-covered. 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. Here is what we need in order to verify your insurance coverage: After getting you a quote for your insurance benefits, Easy Breathe will help you contact your doctor's office for the following: These documents are needed in order to show medical necessity to your insurance company. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Arch Dis Child. Measurements usually involve the detection of wrist movements. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Hypertension in an asymptomatic individual; 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). Effective March 3, 2009. SDB is associated with sleep disorders, such as OSA and also multiple age-related health disorders. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: 1997; 127(8 Pt 1):581-587. J Clin Sleep Med, 2018; 14(7):1231-1237. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry.
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