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Blue Cross Sleep Apnea Coverage

What Is Sleep Apnea

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Sleep apnea is a medical disorder that influences an individuals breathing during sleep. Its triggered by the respiratory tracts being obstructed, resulting in snoring issues, suffocation, absence of sleep, and even fatality.

A specific with severe sleep apnea will certainly have durations of not taking a breath at all for 10 seconds or longer. This will then compel the mind to awaken. Still, it will not go back to sleep due to the fact that its constantly being disrupted by the individuals body attempting to take a breath once more.

The major danger variables for sleep apnea are weight problems, age , huge neck dimension, aging, as well as smoking. There is additionally a vital hereditary component to the disease. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance

Dise Is A Prerequisite To Inspire

If the patient then decides to pursue Inspire therapy, getting Inspire therapy for sleep apnea covered requires a drug-induced sleep endoscopy to asses for the configuration of the soft palate collapse. Concentric collapse at the level of the velopharynx is considered a contraindication.The procedure goes something like this: The physician brings the patient to an outpatient procedure room and induces sleep. The physician is then able to perform a flexible laryngoscopy, putting a flexible endoscope in the patients nose and down to the back of the throat to observe the velopharynx while the patient is asleep.This DISE procedure is billed to the insurance company using CPT® code 31575 Laryngoscopy, flexible diagnostic. Although the physicians time allocated to a DISE patient is significant as an outpatient procedure, the reimbursement is low . Physicians have to look at DISE as part of the greater package for the Inspire treatment.

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What To Think About

If you are thinking about having surgery to treat sleep apnea, talk with your doctor about having a sleep study done first.

Experts typically suggest that you try continuous positive airway pressure before considering surgery.

Laser-assisted uvulopalatoplasty uses a laser to perform surgery. It is sometimes used to treat mild to moderate sleep apnea, although not all people benefit. This surgery is not recommended by the American Academy of Sleep Medicine to treat sleep apnea.footnote 16

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Does My Deductible Apply To Cpap Equipment

Pacific Blue Cross

Typically, your deductible applies to essential CPAP equipment, not including optional accessories. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. If you require more frequent replacements of certain components, those costs may be out of pocket.

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Does Medicare Cover Sleep Apnea

Does Medicare Cover Sleep Apnea? Sleep apnea is a medical condition that causes side effects that range from mildly annoying to downright dangerous. Its believed that sleep apnea affects tens of millions of people across the world, and in the United States, obstructive sleep apnea is a concern for adults of all ages, although men are affected more frequently than women.

Medicare Benefits Solutions

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Medicare coverage for treatment of sleeping disorders is generally covered by Part B. Medicare Part B is the outpatient benefit of the program, and it provides benefits for things like doctor visits, surgery, and durable medical equipment.

Medicare benefits provided by Part B may include coverage for a three-month trial use of a CPAP machine. If the use of a CPAP machine is prescribed by your doctor, Medicare may cover the rental of the equipment for up to 13 months. In order for your machine to qualify, it will need to be prescribed by a Medicare-participating physician, and the equipment will need to be available from a Medicare-approved supplier.After the machine has been in use for 13 months, Medicare pays it off. Keep in mind that Medicare coverage for treatment of sleeping disorders using CPAP follows the standard Part B deductible requirements. This means that you will be responsible for 20% of your costs while Medicare benefits cover the remaining 80%.

Dealing With Sleep Apnea With Cpap Or Surgical Procedure

Some individuals might obtain the therapy they need utilizing CPAP. CPAP is a form of treatment that does not involve surgical treatment. Instead, it functions by giving the person with sufficient oxygen throughout the day to maintain them breathing well in the evening.

If CPAP does not function, there are surgical choices offered. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance

The surgery for sleep apnea relies on eliminating the adenoids and tonsils to open the airway. Despite being an effective therapy option for this condition, it does include some threats.

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How Does Inspire Surgery For Sleep Apnea Work

Inspire surgery is the latest treatment for sleep apnea. It works while youre asleep to keep your airways open, allowing you and your partner to get deep, quiet sleep.

Inspire is a small device that is placed in your upper chest through tiny incisions during a same-day, outpatient procedure. You come back 30 days later to have it programmed, and youre done.

Each night, you simply click the small remote to turn Inspire on. Then, while you sleep peacefully, Inspire delivers mild, imperceptible stimulation to keep your airways open, allowing you to breathe normally and wake refreshed.

You turn off the Inspire stimulator when you wake up. Thats it. No mask, no hose, no loud breathing machine. Just sleep.

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Bluecross Blueshield Insurance For Sleep Apnea


If you are seeing a sleep dentist like Dr. Conditt for treatment, it is likely because you are CPAP intolerant and require an alternative solution to help you achieve a better quality of life. Individuals who cannot use other methods of sleep apnea treatment may find that the only solution to achieving a better quality of life is with oral appliance therapy. While this is a simple, easy-to-use, and more comfortable alternative, you may be asking, Is it covered by medical insurance?

While it might sound a bit strange to file under health insurance instead of dental, especially when seeing a sleep dentist, oral appliances are designated as durable medical equipment in your health insurance policy, making it possible to receive coverage. That is if you are seeing an in-network provider.

The best part about choosing Fort Worth Snoring & Sleep Center to receive sleep apnea therapy is that our team has already done all the legwork to ensure they are in-network with most BlueCross BlueShield policies. Not only does this mean less work for you when trying to find someone who will provide treatment, but it also means your out of pocket expenses will be significantly lower than if you were to seek a provider who is out of network. You can trust that our team will always do a benefit verification before beginning treatment to be sure your specific group plan covers oral appliance therapy in our office.

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How Much Does The Inspire Implant Cost

âA patientâs financial responsibility varies based on the specifics of their individual insurance plan,â Inspire told CNET. âIn general, most patients will only be required to pay the applicable deductibles and copayments that exist for their insurance plan.â

According to Inspireâs website, itâs covered by mostinsurance providers. The exact out-of-pocket cost will depend on your insurance plan. Remember, itâs an outpatient procedure, so there are some medical bills that will have to be taken into account.

However, as an example, the pricing page states that a person with traditional Medicare should expect to pay a maximum of $1,400 out of pocket if the procedure is done in hospital.

You can expect to see a total bill of around $30,000 to $40,000 for both the surgery and device cost, but thatâs before your insurance kicks in. I canât say exactly how much youâll end up paying â it depends heavily on your insurance plan and deductible. If youâre interested in Inspire, itâs best to speak to your provider to discuss your options.

How Is Sleep Apnea Treated

Some lifestyle changes can help sleep apnea. Try losing weight if needed, sleeping on your side, and avoiding alcohol and medicines like sedatives before bed. Sleep apnea is often treated with a CPAP machine or other machine that prevents your airways from closing during sleep. Oral or nasal breathing devices may also help.

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Signs That You May Have Sleep Apnea

The following indicators are just a couple of that can indicate something wrong with your sleep.

We have actually assembled 10 of one of the most common indicators that a person may have sleep apnea, a sleeping problem that interferes with the persons breathing in the evening. Does Blue Cross Blue Shield Federal Cover Sleep Apnea Oral Appliance

They are:.

1) feeling like you cant breathe or like youre choking .

2) loud snoring or wheezing for air .

3) regular awakening in the morning .

4) waking up worn down .

5) too much daytime sleepiness .

6) completely dry mouth, aching throat, or ringing in ears when you awaken .

7) persistent discomfort .

8) exhaustion or difficulty focusing during the day .

9) feelings of clinical depression and anxiousness .

10) weight gain.

Medicare Vs Aasm Guidelines

Does Blue Cross Blue Shield Cover Sleep Apnea Treatment?

Medicare defines RDI as the average number of apneas and hypopneas , they do not include RERAs. In order for Medicare to coverage CPAP for sleep apnea, the patient must meet one of the following criteria for obstructive sleep apnea to be diagnosed:

  • AHI or RDI must at least 15 events per hour .
  • AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness impaired cognition mood disorders insomnia or documented hypertension, ischemic heart disease, or history of stroke.

Some insurances refer to the American Academy of Sleep Medicine standards for RDI which includes apneas, hypopneas or RERAs.

When we, at Advanced Sleep Medicine Services, score sleep studies, we include RERAs in our calculation for RDI.

The AASM requires one of the following criteria be met for a diagnosis of sleep apnea:

If a patient has an RDI greater than 15 but their AHI is under 15, Medicare and other insurances will not approve CPAP therapy for a diagnosis of sleep apnea.

Our experience in California is that some Blue Cross policies , some Blue Cross Blue Shield policies and Aetna will consider RDI when determining coverage. All other commercial plans are following Medicare guidelines.

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Bcbs Wants You To Try Lifestyle Modification

Alongside treatment with oral appliances or CPAP, BCBSNE may recommend that you attempt to reduce your sleep apnea or cure it with lifestyle modification.

Some of the recommended modifications include weight loss, allowing yourself enough time for sleep, side sleeping, quitting smoking with a supervised program, and avoidance of alcohol, caffeine, and sedatives before bedtime. These are not considered standalone treatments, but they are recommended as supplemental treatments that may be recommended when appropriate.

Cpap Coverage By Province:

Once you have been diagnosed with Sleep Apnea, check with your private insurance company how much coverage they offer for CPAP equipment. Keep in mind that each insurance company and each province will be different in how much of the expenses they cover.

Below, we walk you through the funding and coverage options of the following provinces: Ontario, Alberta, British Columbia, Quebec and Nova Scotia.

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What Should I Do If My Insurance Wont Cover Cpap

If you and your doctor determine that CPAP is the best course of treatment, but your insurance will not cover CPAP because you do not meet the Medicare requirements, you have a couple of options:

  • Contact your insurance company. If you do not meet Medicare requirements but meet AASM guidelines, tell them so! Unfortunately, Medicare wont budge unless you have documented symptoms of excessive daytime sleepiness or the other medical conditions listed above.
  • Ask your doctor to contact your insurance company. Your doctors office can review your chart to see if you have other documented symptoms that may help get approval. A call from your physician can go a long way, but it takes a lot of time and effort on their part.
  • Pay cash for a CPAP.
  • Look online for an organization that provides free or low-cost CPAPs .
  • Consider having another sleep study. Your sleep apnea may not have been recorded at its worst on the night of your sleep study. For example, many patients have more severe sleep apnea while in REM sleep or when sleeping on their backs. Your second study may not be covered by your insurance .

Bluecross Blueshield Coverage Availability & Fees

Our Specialty | Empire Blue Cross Blue Shield

Regence BlueCross BlueShield of Oregon manages a sleep medicine program via AIM Specialty Health. The program offers coverage for the following services:

  • At-home sleep tests
  • In-lab sleep studies
  • Titration sleep studies
  • Treatment for sleep disorders, including oral appliances, CPAP, and BiPAP

If you would like to use your BCBS plan to help you pay for the services provided in our office, give us a call and provide us with your policy information. We will get in touch with AIM to request preauthorization for your oral appliance and/or combined therapy. Well also provide you with upfront information about how much you might have to pay out of pocket to cover your deductible, coinsurance, or copay.

If you would like to find out more about how your insurance applies to sleep apnea services before you schedule an appointment with us, your policys online patient portal may have valuable information. Your insurance card may also have a phone number that you can call to get help with your policy. Of course, our team is always willing to help to the extent possible.

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Complications Of Obstructive Sleep Apnea

When you stop breathing because of obstructive sleep apnea, the oxygen levels in your blood go down and carbon dioxide levels go up. This makes your heart and blood vessels work harder and can affect your heart rate and nervous system. That in turn may:

  • Lead to other problems, such as high blood pressure and heart disease.
  • Make these other problems worse and harder to treat.
  • Raise your risk of having a stroke.
  • Make it harder for people with diabetes to control blood sugar.

Pros Of Inspire Sleep Therapy


The Inspire implantable device does not interfere with your daily life, such as exercising, working, and eating, and you wont have the chance to roll out any eccentric developments to your own eating regime, either. Apart from being small, it is also implanted into your body and easily controlled by small a handheld remote, which means you wont need all that extra space for a bulky CPAP machine or go through the hassle of putting it away when you wake up every morning.


In the first year of your Inspire Sleep device implantation, your physician will want to see you periodically, once every several months. However, upon confirmation that the device is working properly and there are no side-effects, you will need to have a checkup once every year.

The battery of the Inspire Sleep device will last around 10 years, after which your remote control will show you signals that the battery is low. You will need to see your physician in order to replace the battery, which is a short and easy procedure.

The battery on your remote is a standard, 9-Volt battery which can be easily replaced.

Simple to Use

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Reasons For Sleep Apnea

The sources of sleep apnea are several as well as not yet totally comprehended. It can be brought on by issues with the size or form of particular soft tissues in the throat or nose, such as the tongue or tonsils, or how well these tissues interact when they relax and also contract. Sleep apnea might additionally be caused by excessive weight.

Repeat Sleep Study Indications

Blue Cross / Medical

It may be necessary to perform repeat sleep studies up to twice a year for any of the following indications. performed in a healthcare facility is considered medically necessary for persons who meet criteria for attended NPSG in section I above in all other cases, unattended sleep studies are considered medically necessary):

  • To determine whether positive airway pressure treatment , demand positive airway pressure , variable positive airway pressure , or auto-titrating positive airway pressure ) continues to be effective in persons with new or persistent symptoms, after interrogation of current positive airway pressure device or
  • To determine whether positive airway pressure treatment settings need to be changed in persons with new or persistent symptoms, after interrogation of current positive airway pressure device. or
  • For persons with substantial weight loss or some other change in their medical condition that would affect the need for continued positive airway pressure treatment , to determine whether continued treatment with positive airway pressure treatment is necessary or
  • To assess treatment response after upper airway surgical procedures and after initial treatment with oral appliances.
  • Note: A home sleep study is performed over multiple nights with a single interpretation is considered a single sleep study for purposes of reimbursement.

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