Can actigraphy measure sleep fragmentation in children? Practice parameters for using polysomnography to evaluate insomnia: an update. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. If you are unable to meet these requirements during the first 3 months, you may have to start the process again. There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Updated Coding section with 01/01/2010 CPT changes. Technology Evaluation Center (TEC) assessments. These plans include: Highmark, Inc.; Blue Cross Blue Shield ("BCBS") of Alabama; and BCBS of South Carolina, which . N Engl J Med. American Academy of Sleep Medicine (AASM) 4 0 obj 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 For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. Practice Parameters for the Indications for Polysomnography and Related Procedures. PAP devices may improve quality of life in individuals with sleep apnea in adults. The terms of your CPAP machine, insurance coverage depends on your provider. 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. 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. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. Take the Sleep Quiz to help inform your sleep improvement journey. No. The two main types of sleep apnea are: 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. Payment will be made for the purchase of the device whenBOTHof the following criteria are met: Throughout the PAP device rental period, the DME supplier must check that the member is compliant with use of the device. Liners are not interfaces for use with a PAP mask. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. 2008; 31(1):141-147. The Rationale, Definitions and References were updated. Effective October 01, 2021, Internal Medical Policy Committee 11-23-2021, Internal Medical Policy Committee 3-23-2022 Coding update- 2019; 46:151-160. Available at: Thurnheer R, Bloch KE, Laube I, et al. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. Arch Fam Med. Silber MH. MPTAC review. Most CPAP machines cost between $500 and $800. Payment will be made for the purchase of the device when More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) O'Driscoll DM, Foster AM, Davey MJ, et al. - Any additional medical records, such as your sleep study, that your insurance company requests. Ann Intern Med. Most other equipment ranges between $20 and $100. PDF Blue Cross Blue Shield of Michigan Medical Policy ; Swiss Respiratory Polygraphy Registry. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Highmark Blue Cross Blue Shield has revised the coverage criteria for the Implantable Pulmonary Artery Pressure Measurement Device. Coding section was updated. 2005; 128(4):2166-2175. Revisions also made to Coding section for clarification of MWT coding. endobj PDF Inspire Medical Systems Inc. Announces Three New Positive Coverage 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. Acoustic Reflection Pharyngometry (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. Pediatr Clin North Am. Policy and Coverage Criteria for Commercial Products: . More than 75 percent of the apneas or hypopneas must have an obstructive pattern. This allows us to help CPAP patients with different insurance carriers in all 50 states, instead of being limited to one service area. Kryger MH. References were updated. Sleep. 2010; 95(12):1031-1033. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. stream A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. Effective April 01, 2023. A provider's office can often get an immediate approval when they submit a request online. Seen as youll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. Coverage continues if your sleep apnea improves with the CPAP treatment. If you're ready for more, sign up to receive our email newsletter! The Blue Cross Obstructive Sleep Apnea in Children The presentation of OSA in children may differ from that of adults. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. Easy Breathe will be happy to call Anthem for you to check how much they will cover with us. References were updated. dX*[D #M:KX{JyIq+R!Iw?p v~pg|A~2vcDTXu9wkZ.fr2{uI)=8y_a{?Et-. Inspire Medical wins more Blue Cross Blue Shield coverage Guilleminault C, Abad VC. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Continued use beyond the first three (3) months of therapy Sleep Medicine - Regence This document addresses selected services for the diagnosis of sleep disorders including: Investigational and Not Medically Necessary: Nap studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy. Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. Marino M, Li Y, Rueschman MN, et al. Second, you must successfully complete a compliance period with the CPAP machine, to demonstrate that you are using the treatment regularly. Participating provider network for custom fitted oral sleep alliances Westbrook PR, Levendowski DJ, Cvetinovic M, et al. 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). Oct 1, 2020 Administrative. 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. Payment will be made for the rental of a PAP device for the first three (3) months (rental period) from the original start date of therapy, when the above clinical criteria are met. Clinical Practice Guidelines | Blue Cross and Blue Shield of Illinois Blue Cross and Blue Shield - CPAP Insurance - Easy Breathe Levenson JC, Troxel WM, Begley A, et al. The term RDI was also corrected to be Respiratory Disturbance Index (not Distress index) and the measure known as RERAS was also added to this definition. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. Measurements usually involve the detection of wrist movements. Our site receives compensation from many of the offers listed on the site. If you have a high deductible under your health insurance policy, you may inadvertently end up covering the full cost of your CPAP machine. Standards of Practice Committee of the American Sleep Disorders Association. Apnea: A transient period where breathing ceases. Addition of acoustic pharyngometry to the testing considered investigational/not medically necessary. You also avoid the insurance requirements of treatment compliance. % OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. Bear in mind that if you are required to rent for longer than a year, you may need to pay a second deductible. 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. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time. Mysliwiec V, Martin JL, Ulmer CS, et al. 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. 2003, 24(2):307-313. If your insurance company determines you are not using the machine frequently enough as per your policy, they may stop covering their portion of the machine rental. Most machines record your use for you. MPTAC review. Your email address will not be published. This limits your coverage options, and you may not get the exact product you desire. Continued use beyond the first three (3) months of therapy. Sleep education. Med Clin North Am. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor. 2000; 3(4):169-172. 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. Updated the formatting of the Position Statement section. Breathing Problems during Sleep. While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis. Easy Breathe is one of the only online CPAP providers able to bill insurance. Fargo, N.D., 58121. Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Arch Dis Child. Another benefit to paying a medical equipment supplier directly is the wider choice of products available to you. Blue Cross Sleep Apnea Coverage - HealthySleepClub.com 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. Townsend D, Sharma A, Brauer E, et al. 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. Again, this will depend on your individual insurance plan and provider, but in the case of Anthem they offer the following replacement schedule: Generally speaking, most insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. These are not considered interfaces as defined in this policy. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. American Sleep Disorders Association and Sleep Research Society. 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. More advanced machines tend to cost more. The medically necessary indications for home portable sleep testing were reordered placing the last criterion for OSA as the first criterion. <> BCBS of North Carolina Weight Loss Surgery - How to Avoid a Denial J Clin Sleep Med. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. However, if your plan has a high deductible, you might be tempted to purchase your CPAP equipment on your own and bypass your insurance. Nasal Expiratory Positive Airway Pressure (EPAP). A trial with CPAP has failed or is contraindicated; The device is prescribed by a treating physician; The device is custom-fitted by qualified dental personnel; There is absence of temporomandibular dysfunction or periodontal disease. 2008; 162(4):350-358. When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. These tests include, but are not limited, to: nap studies, actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. - Power Supplies: CPAP Power Cords and Batteries. Respicardia Announces Highmark Coverage for the rem The Definitions and References were updated. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. According to the American Academy of Sleep Medicine (AASM), updated definitions of OSA severity are provided as follows: Mild OSA: AHI of 5-15, involuntary sleepiness during activities that require little attention, such as watching TV or reading; Moderate OSA: AHI of 15-30, involuntary sleepiness during activities that require some attention, such as meetings or presentations; Severe OSA: AHI of more than 30, involuntary sleepiness during activities that require more active attention, such as talking or driving (AASM, 2008). of the following criteria are met: Throughout the PAP device rental period, the DME supplier must check that the member is compliant with use of the device. Easy Breathe works with your Blue Cross PPO plan as an out-of-network provider. Young T, Skatrud J, Peppard PE. More expensive accessories often come with warranties of 1 to 3 years. Insurance providers almost always request that you present an obstructive sleep apnea diagnosis before starting coverage for a CPAP machine and related equipment. 2019; 10:551. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. Available at: Berry RB, Quan SF, Abreu AR, et al. 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. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint. AIM will also manage treatment options for positive airway pressure (PAP) devices and related supplies/oral appliances for obstructive sleep apnea. This means your doctor still needs to conduct a sleep study to give you a diagnosis. Fletcher EC, Stich J, Yang KL. Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. Your AHI must also meet the same requirements as for Medicare: If you meet these requirements, then Medicaid provides CPAP coverage for a 12-week trial. Liners are not interfaces for use with a PAP mask.
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