Anthem Blue Cross Blue Shield
In general, Anthem seems to cover sleep apnea treatment when this treatment follows specific clinical guidelines. It refers patients to the website of AIM Specialty Health for the management of their sleep apnea. AIM’s clinical guidelines suggest that insurance may cover any and all of the following when deemed appropriate:
- Home sleep test
- In-lab sleep study
- Titration study
- Initial and ongoing treatment with CPAP or other airway treatment
- Oral appliances
AIM guidelines recommend home sleep tests for most individuals (and Anthem has praised their cost-effectiveness), especially for follow-up tests to ensure CPAP is effective. Anthem also notes that pre-authorization is required for CPAP, and that a person must be monitored to ensure proper use of CPAP, which is defined as 4 or more hours a night on 70% of nights.
CPAP is recommended when a person has AHI of 15 or greater or an AHI of 5-14 and sleep apnea symptoms like:
- Excessive daytime sleepiness
- Impaired cognition
- Mood disorders
- Treatment-resistant hypertension
- Ischemic heart disease
- Stroke history
Oral appliances are only recommended if AHI is 15-30 or it is 5-14 and a person is manifesting the symptoms above. In addition, you have to either not be candidate for CPAP or failed in your compliance, despite a 45 day trial with a compliance program. In addition, you can request an oral appliance as your initial treatment.
AIM’s documentation doesn’t reference surgical approaches. To be clear, these recommendations don’t officially position themselves as coverage documentation.
United Healthcare offers more straightforward documentation of what it covers. It notes that oral appliances are considered proven and medically necessary for treating obstructive sleep apnea. However, it does note that they are unproven for central sleep apnea. It also notes that nasal dilator devices are unproven. The criteria for oral appliance usage are similar to above, AHI of 15-30 or 5-14 with sleep apnea symptoms. In addition, coverage is available for oral appliances if a person has an AHI of 30+ and are unable to tolerate CPAP.
United also says that surgical sleep apnea treatments are proven and medically necessary. Surgical techniques that may be covered include uvulopalatopharyngoplasty (UPPP), Maxillomandibular advancement surgery (MMA), radiofrequency ablation of the soft palate and/or tongue, as well as combination procedures.
CPAP is covered for people who have sleep apnea. Initial coverage of CPAP is limited to 12 weeks. After that, you have to prove that you can comply with sleep apnea usage requirements (similar to above) in order to extend coverage.
Diagnosis of sleep apnea is also covered, which may include diagnostic x-rays, pharyngoscopy, oximetry testing, and polysomnography.
Aetna Health recommends at-home sleep testing to diagnose sleep apnea. It only recommended attended full-channel sleep apnea when a person has comorbid medical conditions and sleep disorders, has had previously inaccurate results, or can’t operate a home sleep test. Most other diagnostic approaches are considered experimental and are not covered. Sleep studies may need to be repeated as much as twice a year to ensure treatment effectiveness.
Aetna assumes that all sleep apnea treatment will include recommendations for lifestyle modifications. CPAP is considered the best frontline treatment. It is recommended if a sleep test shows an AHI of 15 or more, or 5 to 15 with sleep apnea symptoms.
Oral appliances are covered when a person has an AHI of 15-30, an AHI of 5-15 and documented sleep apnea symptoms, or if their AHI is 30+ and they’re unable to tolerate CPAP or CPAP isn’t recommended.
Surgical approaches may be covered. Coverage for UPPP is contingent on trying CPAP and having some response. Jaw realignment and tracheostomy are covered when a person doesn’t respond to other sleep apnea treatments.
Cigna covers a sleep study to diagnose sleep apnea for people who have evidence of daytime sleepiness and any of the listed risk factors, such as:
- Witnessed cessation of breathing
- Gasping or choking during sleep
- High neck circumference
Sleep tests are also covered to ensure that sleep apnea treatment, especially CPAP, is effective. In-lab sleep tests are used only when there are comorbid health or sleep conditions, or if a person has had an inadequate home test.
CPAP is covered if AHI is greater than 15, or greater than 5 and accompanied by symptoms of sleep apnea. Initial coverage is limited to 90 days, when effectiveness and compliance must be established to maintain coverage. Coverage only includes one type of mask.
Oral appliances (including tongue retaining devices) are covered for sleep apnea when AHI is 15-30, it’s 5-15 and accompanied by sleep apnea systems, or it’s 30+ but a person cannot comply with CPAP treatment.
Surgical treatments may be covered. Tonsillectomy and/or adenoidectomy are covered. UPPP is covered if the is a collapse of the retropalatal region and CPAP or oral appliance has been considered. Multilevel surgery may be covered if anatomy affecting the airway at several sites can be confirmed. MMA is allowed for severe sleep apnea when nonsurgical treatments have failed. Tracheostomy is covered when other treatment options have failed or been refused.
Because of the way Kaiser Permanente functions, sleep apnea procedures are generally handled by their doctors and other providers. Except for special circumstances, coverage only applies for treatment undertaken by their network of providers.
Want to Learn If You’re Covered?
Insurance information is complicated, and we can best answer your questions if you have a consultation when we can look at your insurance information. To schedule a consultation with Denver sleep dentist Dr. Kevin Berry and his support staff, please call (303) 691-0267 for an appointment at the TMJ Therapy & Sleep Center of Colorado.