Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. Am J Respir Crit Care Med. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. endobj eligible for coverage. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed. The appropriate setting for standard CPAP treatment is determined during a titration sleep study. Blue Care Network's medical policy on the diagnosis and management of obstructive sleep apnea includes coverage for home sleep studies for members with symptoms of OSA without other comorbid conditions. Coveredsleep apneaDiagnosis Codes for Procedure Code E0601, Non-Covered Diagnosis Codes for Procedure Code E0471. Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health) Improving the quality . 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). Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading. MPTAC review. Obstructive sleep apnea. We work with Anthem Blue Cross and Blue Shield PPO plans nationwide. American Academy of Pediatrics (AAP). Not sure what your Blue Cross insurance covers? 1997; 20(12):1208. As you adjust to CPAP treatment, you may desire additional accessories for more comfortable sleep and easier travel. However, how often they replace these, and how much of the cost your insurance covers, of course depends on your policy and the company youre with. Our site receives compensation from many of the offers listed on the site. Network Coverage In-network care only, except in certain situations like emergency care Out-of-Pocket Maximum (PPO) . Collop NA, Tracy SL, Kapur V, et al. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. Policy Statement . The Rationale, Definitions and References have been updated. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. 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. The machine attaches to a mask that you wear over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Replacement of PAP Devices Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. This limits your coverage options, and you may not get the exact product you desire. 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). 1 0 obj N Engl J Med. 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. Shift work sleep disorder (SWSD): A sleep disorder that is related to unusual or constantly changing work schedules and results in symptoms of insomnia or excessive sleepiness. 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). If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. 2003, 24(2):307-313. Subject: Sleep Testing - Florida Blue A replacement device is not covered if due to misuse or abuse and is considered a non-covered service. American Sleep Disorders Association and Sleep Research Society. 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. Payment will be made for the purchase of the device when 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 Pediatrics. Diagnosis of Sleep Disorders and Treatment of Obstructive Sleep Apnea, Polysomnography and Other Sleep Studies in Adults, Polysomnography and Other Sleep Studies in Children. Updated Coding section with 01/01/2009 CPT changes; removed 0089T deleted 12/31/2008. The effective date is February 26, 2018. Recommendations from other national entities may vary. 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. Continued use beyond the first three (3) months of therapy An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. endobj 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).
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