Print

Date Printed: December 18, 2017: 11:25 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Subject: Positive Airway Pressure Devices

Member View

inical_view_eng_btn mber_view_sp_btn

 

This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION

Positive airway pressure devices help to treat obstructive sleep apnea (OSA). OSA affects 2 to 4% of adults in the U.S. A sleep-related breathing disorder, OSA occurs when your breathing frequently stops or diminishes while you sleep. This can limit the amount of oxygen you take in and can cause health problems. These may include sleepiness, heart problems, high blood pressure and loss of focus.

To determine if you have OSA, your doctor may ask you to do a sleep study. During the study, a clinical team will observe you while you sleep for one full night. When the test is done, you receive a score. A score of more than 5 may mean you have OSA.

Your doctor may then prescribe a positive airway pressure (PAP) device. Several different types of devices are available. Most consist of a face mask that fits over the nose and mouth. The mask connects to a machine that delivers low levels of air pressure. This helps you continue breathing while you sleep at home. Typical devices include the continuous positive airway pressure (CPAP) device and the bi-level positive airway pressure (BiPAP) device.

PAP devices are also used to provide breathing assistance if you suffer from certain illnesses such as chronic obstructive pulmonary disease (COPD).

Visit the Clinical View of this guideline for more information.

Visit WebMD for more information on using positive airway pressure devices.

COVERAGE

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.

 

Florida Blue may consider a PAP device medically necessary for OSA or other illnesses. You must meet certain requirements. An initial trial period for the use of a PAP device is three (3) months. After this time, your doctor should revaluate your need for the device. If the device helps, coverage may continue.

Visit the Clinical View of this guideline for specific coverage information.

PROGRAM EXCEPTIONS

• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: December 18, 2017: 11:25 AM