What Is The Cost Of A Sleep Study With Insurance
Its nearly impossible to capture all of the variations in reimbursement schedules from one insurance payer to the next, especially with so many different avenues for applying insurance benefits .
However, here are some highlights and generalized guidelines for determining if, how, and when your insurer will cover your sleep study.For the purposes of this post, the discussion centers only on private insurance carriers and not CMS/Medicare/Medicaid.
Hypoglossal Nerve Stimulator Services
Despite AASM advocacy efforts for CMS to finalize the work RVUs for these three codes, consistent with the higher RUC recommendations, the agency finalized work RVUs of 14.00 for CPT code 64582, 14.50 for CPT code 64583 and 12.00 for CPT code 64584. However, CMS is finalizing the RUC-recommended direct practice expense inputs without refinement for all three codes.
Compliance Monitor For Oral Appliances
The American Academy of Sleep Medicine and the AADSMs clinical practice guideline on The treatment of obstructive sleep apnea and snoring with oral appliance therapy stated that There are several recent non-RCTs published that report on the use of objective adherence monitors in OAs. Further RCTs are needed to evaluate the efficacy of these monitors and also to compare it with the CPAP objective adherence rate.
Furthermore,, an UpToDate reviews on Oral appliances in the treatment of obstructive sleep apnea in adults does not mention the use of compliance monitors.
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Questions To Ask Your Sleep Surgeon
It is important to have a comprehensive understanding of the role of this treatment in your condition. The first choice for the treatment of obstructive sleep apnea is the use of continuous positive airway pressure . Success with this treatment requires proper mask fitting and optimal device settings.
In some cases, alternatives such as weight loss, bilevel therapy, the use of an oral appliance, or positional therapy can be pursued. In some cases, nothing seems to work.
Once you have exhausted treatment options with your board-certified sleep physician, it may be necessary to consider the role of the Inspire hypoglossal nerve stimulator. Consider some of these questions to ask the surgeon:
- Am I a good candidate for the surgery?
- If you couldnât do this surgery, what would they recommend as treatment instead?
- How often have they done this procedure?
- What is their success rate in resolving sleep apnea ?
- How many patients have complications such as bleeding, infection, or device removal?
- How will I know if the therapy works well for me?
- Do they have support to work through the insurance approval process?
- Will I have testing after the device is placed to determine settings and response to therapy?
- Who will I follow up with once the surgery is complete?
There may be additional considerations based on your specific circumstances.
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What Is Sleep Apnea
Sleep apnea, opens new window is a sleep disorder that causes long pauses in breathing during sleep. There are several types of sleep apnea, including obstructive sleep apnea , central sleep apnea and mixed sleep apnea. Anyone can develop sleep apnea, but its more common in older adults and affects men more than women.2
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Does Medicare Cover In
In 2008, the Centers for Medicare and Medicaid Services updated the National Coverage Determination for CPAP to include home sleep apnea testing as a means to qualify patients with obstructive sleep apnea for CPAP therapy .
HST is a type of diagnostic polysomnography which is self-administered by the patient in his/her home. It is used to diagnose sleep apnea by recording several channels of information: respiratory effort, pulse, oxygen saturation, nasal flow and snoring. HST is a cost-effective alternative to in-center sleep testing for many patients if it is highly likely that the patient has moderate to severe sleep apnea, and if the patient has no other significant medical issues such as pulmonary diseases, neuromuscular disease or congestive heart failure. HST cannot be performed on children and cannot diagnose other sleep disorders such as restless leg syndrome, periodic limb movement disorder or narcolepsy. These patients should be tested in a sleep center .
You can read the American Academy of Sleep Medicine clinical guidelines for home sleep testing here.
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Meet Medical Necessity Requirements
Many insurance plans, including Medicare Part B, cover home sleep tests for eligible patients. The physician services related to HSTs are covered for testing a patient for the diagnosis of SA, insomnia with SA, hypersomnia with SA, or sleep-related hypoventilation/hypoxemia.Medicare will cover a HST only for patients with a high pretest probability of moderate to severe obstructive sleep apnea . If the patient does not have OSA, the home study test will not be able to test for, or determine, what other sleep disorder may be present.HSTs are not covered for Medicare patients with:
- Other sleep disorders or
- For screening asymptomatic persons.
If a diagnosis is not established based on the results of the testing, perhaps because of inadequate results, the provider can code the patients signs and symptoms that prompted the order for the test. If the insurance company rejects the claim, an appeal can be submitted based on documentation in the medical record that was obtained prior to testing.
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Sleep Studies For Diagnosing Obstructive Sleep Apnea
Sleep studies are often required to formally diagnose patients with sleep apnea.
You must undergo a face-to-face evaluation with your doctor prior to your sleep study. Your obstructive sleep apnea symptoms must be documented in your medical record before your doctor writes an order or referral for a sleep study.
Four Types of Sleep Studies Covered by Medicare
- Type I
- This type of attended sleep study is covered by Medicare when it is performed at a facility with the oversight of a sleep technologist to aid the diagnosis of obstructive sleep apnea. Type I, which is typically performed in a facility, is considered the reference standard for diagnosing obstructive sleep apnea.
- Type II
- Type II is a home sleep test performed using a portable monitor with a minimum of seven channels. Medicare covers Type II testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
- Type III
- Type III is a home sleep test performed using a portable monitor with a minimum of four channels. Medicare covers Type III testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
- Type IV
- Type IV uses at-home sleep study devices that measure, at a minimum, three channels: airflow, heart rate and oxygen saturation. Medicare covers Type IV testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
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Medicare Coverage For Treating Sleep Apnea
Medicare covers the diagnosis and treatment of obstructive sleep apnea when certain criteria are met.
Sleep apnea is a serious medical condition in which a patient stops breathing during sleep. It is often underdiagnosed.
The prevalence of sleep apnea increases with age. Up to 10 percent of people aged 65 and older have the condition.
Complications associated with sleep apnea include:
- Excessive daytime sleepiness
- Coronary artery disease
A continuous positive airway pressure, or CPAP, machine, is the treatment of choice for obstructive sleep apnea.
Medicare Part B partially covers the cost of a CPAP machine as durable medical equipment.
In order to receive a CPAP machine through Medicare, you must first undergo a sleep study.
After the sleep study, your primary care doctor will review the results with you during a follow-up appointment.
Your doctor will use the data gathered to determine a formal diagnosis and discuss any treatment or further evaluations you may need.
Other Criteria to Receive a CPAP Machine through Medicare
- The CPAP must be ordered by your doctor.
- Your doctor must teach you or your caregiver how to use the machine before you receive it.
- Your obstructive sleep apnea diagnosis must include a clinical evaluation of a sleep study performed in a sleep laboratory or an unattended home sleep test with a Type II, Type III or Type IV home sleep monitoring device.
When you meet specific criteria, Medicare Part A should cover the surgery.
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Does Medicare Cover Sleep Apnea
Home / FAQs / Medicare Coverage / Does Medicare Cover Sleep Apnea
Sleep apnea is a common condition with which many people struggle. Medicare Part B provides coverage for sleep apnea including doctor visits, sleep studies, and equipment to treat the disorder. Depending on the Medicare plan you have, you may be responsible for a portion of the cost.
What Is Out Of Center Sleep Testing
Out of Center Sleep Testing refers to options including Home Sleep Tests , Portable Monitoring , and Out Of the Facility testing.
For a provider to be accredited as a legitimate OCST entity by the AASM, and subsequently potentially covered by Medicaid, the provider must be able to verify the attendant physicians training, knowledge, and experience. As sleep study enrollees must undergo very thorough examinations, the AASM considers the skill and accuracy of the physicians diagnostic capabilities absolutely vital. Any physician issuing medical direction during these studies must possess a valid practitioners license in the corresponding state. It’s also expected that the physician routinely updates and educates the sleep study participant after evaluation, diagnosis and development of a proper treatment plan.
In addition, at least one properly educated and experienced technician must also be present throughout the duration of the study, and the space and equipment used must be in accordance with the AASMs documentation requirements.
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Who Can Interpret A Sleep Study For A Medicare Patient
Once the sleep study is completed and the data is scored, the report is sent to a sleep specialist for review and interpretation. Only a sleep boarded or board-eligible physician can interpret sleep studies for Medicare patients. The physician must meet one of the following requirements:
- Current certification in Sleep Medicine by the American Board of Sleep Medicine or,
- Current subspecialty certification in Sleep Medicine By a member board of the American Board of Medical Specialties or
- Completed residency/fellowship training by an ABMS member board
- Completed all requirements for subspecialty certification in sleep medicine and only until the time of reporting of the first exam which physician eligible or,
What Causes Sleep Apnea
There are several factors that can cause sleep apnea in adults. The primary risk factor is obesity since fat deposits around the throat can press down on your upper airways and constrict normal breathing. The use of alcohol, smoking, and nasal congestion can all constrict your breathing as well. Other risk factors are hereditary, such as a naturally thicker neck, narrower throat, being male, being older, and a family history of sleep apnea.
Luckily, sleep apnea is treatable, with treatment usually combining lifestyle changes such as losing weight and quitting alcohol and smoking, to wearing a nighttime mask called continuous positive pressure device which keeps your airway open while you sleep. However, there is a new device that is more convenient and sleep-friendly than bulky CPAP masks Inspire Sleep.
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Why Is Obstructive Sleep Apnea A Health Problem
When you experience apnea, you begin to be starved off oxygen. Your brain will then wake you up to force you to breathe, resulting in interruptions to your sleep. In OSA, those interruptions can many as 30 interruptions per sleep session. Additionally, the constant apnea can result in the most common sign of OSA: loud snoring.
Uninterrupted sleep is essential to entering deep sleep, a stage of sleep necessary for the mind and body to recuperate and rebuild itself each day. Without that, you can begin to experience daytime fatigue, memory loss, poor emotional control, and be at increased risk for heart disease. This is because the heart must exert more effort in getting oxygen to your brain. The earlier you can prevent this, the better it is for your heart health.
We Accept Medicare For Sleep Treatment
For people without traditional medical insurance who are worried about being able to afford sleep apnea therapy, we have good news: Medicare can be used to pay for a sleep oral appliance, and EZ Sleep Solutions is happy to accept many different Medicare plans as well. And, depending on your particular plan, Medicare can be used to cover much more than just an oral appliance. Our team can make the claim process nice and simplewell handle all the paperwork so you can save as much as possible without having to stress or wait. To learn how we could use your specific plan to help pay for your sleep care,give us a call today.
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Will Medicare Cover A Cpap Machine
Medicare covers CPAP machines used to treat sleep apnea under the durable medical equipment benefit. To qualify for CPAP coverage, you must meet the following requirements:
- Complete a sleep test in a laboratory setting or by using an approved at-home test
- Be diagnosed with obstructive sleep apnea based on sleep test results
- Have a prescription for a CPAP machine from your doctor
- Get the CPAP machine from a participating Medicare supplier
Since CPAP treatment doesnt work for everyone, Medicare first covers the machine for a three-month trial period. After three months, your doctor will check how the treatment is working for you. Medicare may cover CPAP therapy long term if your doctor verifies in your medical record that you are using the machine and that its helping you.