Extended! Free CME credits for Training On Bias in Maternal Health Costs for these products can vary depending on the quality. An Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 13 Benefits Application American Academy of Pediatrics (AAP). Blue CareOnDemand is available 24/7, 365 days a year, from your computer or smartphone. Providers have the opportunity to review . Westchester, IL: American Academy of Sleep Medicine; 2007. Policy and Coverage Criteria for Commercial Products: The AIM Clinical Appropriateness Guidelines include medical necessity criteria for Sleep Disorder Management: SDB is a common disorder that results in oxidative stress and inflammation of the upper airway. Medical and surgical treatments for obstructive sleep apnea syndrome are in benefit. Government Agency, Medical Society, and Other Authoritative Publications: ActigraphyApnea/Hypopnea Index (AHI)Apnea Risk Evaluation System (ARES)Nap StudyObstructive Sleep Apnea (OSA)Pharyngometry AcousticQuantitative EEG MappingSleepStripSNAP Testing SystemStatic Charge Sensitive BedsTopographic EEG Mapping. A provider's office can often get an immediate approval when they submit a request online. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. References and Coding were updated. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. 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. Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary. It can be mild, moderate, or severe, based on the number of times each hour that breathing stops (apnea) or slows (hypopnea). 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). 2001; 285(22):2936. American Academy of Sleep Medicine (AASM). Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. Medical policy list | Blue Shield of CA Provider 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). PAP devices may improve quality of life in individuals with sleep apnea in adults. Damon Wiseley is a Registered Respiratory Therapist and Certified Pulmonary Function Technologist. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. Home/Portable sleep study (may also be known as NightWatch System, AutoSet Recorder, Morpheus System): A diagnostic test proposed for home use which may be self-administered or attended by a technician. Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Medical Benefits Management for Sleep Disorder Management. CPAP therapy is effective, but it can also be expensive. Patient Page. 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. There is additionally a vital hereditary component to the disease. Sleep disorder: A disruptive pattern of sleep that may include difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep. Most machines record your use for you. Levenson JC, Troxel WM, Begley A, et al. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. 3 months/90 days. 2009; 5(3):263-276. References were updated. PDF Medical Coverage Policy | Oral Appliances for Sleep Apnea - BCBSRI Marcus CL, Brooks LJ, Draper KA, et al. E 1 0 obj 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. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Liners are products placed between the individuals skin and the PAP mask interface and are made of cloth, silicone or other materials. Keep in mind that whether or not you use insurance, medical equipment sellers require a CPAP prescription in order for you to purchase the machine and equipment. He has tested hundreds of mattresses and sleep products. According to the OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. Sleep Management - Blue Cross Blue Shield of Massachusetts Upper airway: The area of the upper respiratory system including the nose, mouth and throat. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. J Clin Sleep Med. However, youre probably wondering about insurance. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. 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 Pediatr Clin North Am. Available at: Chesson AL Jr, Ferber RA, Fry JM, et al. We regularly assess how the content in this article aligns with current scientific literature and expert recommendations in order to provide the most up-to-date research. Removed ICD-9 codes from Coding section. SleepFoundation.org is not affiliated with the National Sleep Foundation, an independent nonprofit based in Washington, DC. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation. Because CPAP machines and their tubing are required daily, theyre subject to significant wear and tear, so you may be wondering how often insurance will cover CPAP supplies. J Clin Sleep Med. The document header wording was updated from Current Effective Date to Publish Date. References were updated. 3 results found for search term : sleep apnea Hypertension Programs and resources to help you prevent and manage hypertension. Products or services advertised on this page may be offered by an entity that is affiliated with us. Your coverage which services your plan helps pay for and how the payment structure works depends on the terms of your specific plan. <> This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. Assessing efficacy, outcomes and cost savings for patients with obstructive sleep apnea using two diagnostic and treatment strategies. 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 . Devices Used for the Treatment of Sleep Apnea in Adults Horizon Blue Cross Blue Shield of New Jersey partnered with the March of Dimes to offer an eLearning session on implicit bias called Awareness to Action: Dismantling Bias in Maternal and Infant Healthcare. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. First, you must have a prescription for CPAP therapy from your healthcare provider. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. 2007; 30(4):519-529. MPTAC review. You also avoid the insurance requirements of treatment compliance. Internal Medical Policy Committee 3-23-2022 Coding update-Added new procedure codes K1028 & K1029, effective April 01, 2022, Fargo (Headquarters) Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual or greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention). 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). However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Kryger MH. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . 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. Call Carelon's Contact Center at 1-866-745-1783 Available Monday through Friday, 8 a.m. - 6 p.m. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. MPTAC review. Interpretation Obstructive Sleep Apnea (OSA) syndrome consists of a collection of symptoms including daytime sleepiness, fatigue, snoring, and restless sleep with a disrupted sleep pattern. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. PDF Blue Cross and Blue Shield of Illinois Provider Manual - BCBSIL Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. Hypertension Programs and resources to help you prevent and manage hypertension. Hypertension The title was changed from: Diagnosis of Sleep Disorders to: Multiple Sleep Latency Testing and other Sleep Testing Services. References were updated. The American Academy of Sleep Medicine (AASM) Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults, updated in 2009, stated: Actigraphy alone is not indicated for the routine diagnosis of obstructive sleep apnea (OSA) but may be a useful adjunct to portable monitors (PMs) when determining the rest-activity pattern during the testing period (Option) (Epstein, 2009). 2007; 146(3):157-166. Most other equipment ranges between $20 and $100. Oct 1, 2020 Administrative. 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). Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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. Inspire Medical wins coverage from five more BCBS plans Obstructive sleep apnea (OSA): This is a form of sleep disturbance, which occurs as the result of a physical occlusion of the upper airway during sleep, which interferes with normal breathing. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. N Engl J Med. Liners are not interfaces for use with a PAP mask. With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Premera Blue Cross, the largest health plan in the Pacific Northwest covering over 2.1 million members in Washington and Alaska. JAMA. 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. Coverage continues if your sleep apnea improves with the CPAP treatment. In order to give you a prescription for a CPAP machine, your doctor must confirm that your sleep difficulties are caused by sleep apnea and not by another condition. endobj Information was added to the Rationale section regarding MWT, taken from the 2005 updated guideline on Practice Parameters for Clinical Use of MSLT and MWT from the American Academy of Sleep Medicine. The Rationale, Definitions and References were updated. The members contract benefits in effect on the date that services are rendered must be used. A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults. 2005; 128(4):2166-2175. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. If the device isn't being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. 2000; 3(4):169-172. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. 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. Swiss Med Wkly. 2003; 87(4):803-833. BCBS of Kansas, which covers approximately 560,000 members.. Review your policy to learn about the requirements specific to your insurance provider. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. There are a number of optional accessories you can purchase for your CPAP machine. Behavioral Health Companion Benefit Alternatives (CBA) manages behavioral health benefits for the State Health Plan. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. On the other hand, if you have a co-insurance plan, you will also be billed monthly for the rental cost of the device, alongside your insurance company. 2020; 172(5):325-336. 7it%:@zBdUyp}>3-2`Z62pVZHc0xLc8#* NXnr80(2 MPTAC review. 2019; 46:151-160. 1. 2002; 109(4):e69. BCBSNC will provide coverage for surgery for obstructive sleep apnea and upper airway resistance syndrome when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. 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. Either a heated humidifier or a non-heated humidifier is eligible for use with a covered PAP device when prescribed by the treating physician to meet the needs of the individual. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. criteria for Sleep Disorder Management: Bi-Level Positive Airway Pressure (BPAP) Devices Management of Obstructive Sleep Apnea (OSA) Oral . Hyde M, O'Driscoll DM, Binette S, et al. State of South Carolina - Coverage Information Gone To See The River Man Ending Explained, Princess Alexandra Hospital Orthopaedics, Police Incident In Carluke Today, Articles B
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