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Medical Policy: 07.01.21
Original Effective Date: January 2001
Reviewed: July 2011
Revised: July 2011
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Obstructive sleep apnea syndrome (OSA) is characterized by repetitive episodes of upper airway obstruction due to the collapse of the upper airway during sleep. Air enters the nose, mouth and throat as it passes to the lungs. Normally the throat is flexible and tends to collapse inward with breathing. Muscles work to oppose the collapse and keep the airway open. Interference or defects in this process cause air turbulence. If tissues in the back of the throat collapse causing momentary blockage, apnea occurs. Breathing stops temporarily. The patient is usually unaware of it, but sometimes may awaken gasping for breath. When interference is incomplete causing continuous, slow, shallow breathing , obstructive hypopnea occurs. Oxygen in the blood is reduced due to the apnea, and eventually the lack of oxygen activates the lungs to suck in air. In patients with OSA, the normal pharyngeal narrowing is accentuated by anatomic factors, such as a short, fat "bull" neck, elongated palate and uvula, or large tonsillar pillars with redundant lateral pharyngeal wall mucosa. Furthermore, OSA may be associated with a wide variety of craniofacial abnormalities, including micrognathia, retrognathia, or maxillary hypoplasia. In addition, OSA is associated with obesity. Obstruction anywhere along the upper airway can result in apnea. Therefore, OSA is associated with a heterogeneous group of anatomic variants producing obstruction.
The hallmark clinical symptom of OSA is excessive snoring. The snoring abruptly ceases during the apneic episodes and during the brief period of patient arousal and then resumes when the patient again falls asleep. Sleep fragmentation associated with repeated arousal during sleep can lead to impairment of daytime activity. For example, patients with OSA-associated daytime somnolence are thought to be at higher risk for accidents involving motorized vehicles, i.e., cars, trucks, or heavy equipment. OSA in children may result in neurocognitive impairment and behavioral problems. In addition, OSA affects the cardiovascular and pulmonary systems. For example, apnea leads to periods of hypoxia, alveolar hypoventilation, hypercapnia, and acidosis. This in turn can cause systemic hypertension, cardiac arrhythmias, and cor pulmonale. Systemic hypertension is common in patients with OSA. Severe OSA is also associated with decreased survival, presumably related to severe hypoxemia, hypertension, or an increase in automobile accidents related to daytime sleepiness.
Upper airway resistance syndrome (UARS) is a variant of OSA that is characterized by a partial collapse of the airway resulting in increased resistance to airflow. The increased respiratory effort required results in multiple sleep fragmentations as measured by very short alpha electroencephalographic (EEG) arousals. Snoring may not be a feature of UARS. The resistance to airflow is typically subtle and does not result in apneic or hypopneic events. However, it does result in increasingly negative intrathoracic pressure during inspiration, which can be measured using an esophageal manometer as an adjunct to a polysomnogram. Therefore, this diagnosis rests on polysomnographic documentation of >10 EEG arousals per hour of sleep correlated with episodes of reduced intrathoracic pressures.
In adults,OSA is often suspected on the basis of the clinical history and physical appearance; i.e., an overweight individual with a "bull" neck. The most common symptoms are snoring, excessive daytime sleepiness, and hypertension.
The gold standard diagnostic test for sleep disorders is considered a polysomnogram, performed in a sleep laboratory. A standard polysomnogram, supervised by a trained technologist, typically includes:
- EEG (to stage sleep, detect arousal)
- Submental electromyogram
- Electro-oculogram (to detect arousal, rapid eye movement [REM] sleep)
Additional parameters of sleep that may be measured include:
- Respiratory airflow and effort (to detect apnea)
- Oxygen desaturation
- Electrocardiography
- Sleep position
- Penile tumescence
- Gastroesophageal reflux
- Continuous blood pressure monitoring
- Snoring
The first 3 elements listed here (EEG, submental electromyogram, and electro-oculogram) are required for sleep staging. By definition, a polysomnogram always includes sleep staging, while a cardiorespiratory "sleep study" does not. The actual components of the study will be dictated by the clinical situation. Typically, the evaluation of OSA includes sleep staging to assess arousals from sleep, and determination of the frequency of apneas and hypopneas from channels measuring oxygen desaturation, respiratory airflow and respiratory effort.
Supervision of the test may be considered important to ensure that the monitors are attached appropriately to the patient and do not become dislodged during the night. In addition, an attendant can identify severe OSA so that the effective level of continuous positive airway pressure (CPAP) therapy can be determined. These studies are known as "split-night" studies, in which the diagnosis of OSA is established during the first half of the night and CPAP titration is conducted during the second half of the night. If successful, this strategy can eliminate the need for an additional polysomnogram for CPAP titration.
In adults, an obstructive apnea is defined as at least a 10-second cessation of respiration associated with ongoing ventilatory effort. Obstructive hypopnea is a reduction, but not a cessation of air exchange, with an associated fall in oxygen saturation (at least 3%–4%) or arousal. The apnea/hypopnea index (AHI) may also be referred to as the respiratory disturbance index (RDI). The AHI is defined as the total number of events per hour of sleep. When sleep onset and offset are unknown, the RDI may be calculated based on the total recording time. A diagnosis of OSA syndrome is accepted when an adult patient has an AHI >5 and symptoms of excessive daytime sleepiness or unexplained hypertension. An AHI greater than or equal to 15 is typically considered moderate OSA, while an AHI greater than 50 is considered severe OSA. Due to faster respiratory rates in children, pediatric scoring criteria define an apnea as 2 or more missed breaths, regardless of its duration in seconds. Hypopneas are scored by a 50% or greater drop in nasal pressure and either a >3% decrease in oxygen saturation or an associated arousal. In pediatric patients, an AHI >1.5 is considered abnormal and an AHI of 15 or more is considered severe. Although there is poor correlation between AHI and OSA symptoms, an increase in mortality is associated with an AHI of greater than 15 in adults. Mortality has not been shown to be increased in adult patients with an AHI between 5 (considered normal) and 15. Sources of measurement error with polysomnography include data loss, artifact, event recognition errors, measurement errors, use of different types of leads, and night-to-night variability.
It is estimated that about 7% of adults have moderate or severe OSA and 20% have at least mild OSA, and that the referral population of OSA patients represents a small proportion of patients who have clinically significant and treatable disease. In light of the limited capacity of sleep laboratories, a variety of devices have been developed specifically to evaluate OSA at home. These range from portable full polysomnography systems to single channel oximeters. Available devices evaluate different parameters, which may include oximetry, respiratory and cardiac monitoring, and sleep/wake activity, but the majority of portable monitors do not record EEG. It has been proposed that unattended studies with portable monitoring devices may improve the diagnosis and treatment of patients with OSA, although the limited number of channels in comparison with full polysomnographic recording may decrease the capability for differential diagnosis or detection of comorbid conditions.
The multiple sleep latency test measures how quickly the patient falls asleep when instructed to relax in a quiet and dimly lit room, and the maintenance of wakefulness test measures sleep latency when the patient is instructed to attempt to remain awake in an unstimulating environment. These tests are not considered necessary to evaluate sleep apnea, but the multiple sleep latency test may be used when symptoms, including excessive daytime sleepiness, suggest narcolepsy.
Excessive daytime sleepiness may be subjective, and may be assessed by questionnaires such as the Epworth Sleepiness Scale; a short self-administered questionnaire that asks patients, “How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?”
- Sitting and reading
- Watching TV
- Sitting inactive in a public place, i.e., theater
- As a passenger in a car for 1 hour without a break
- Lying down to rest in the afternoon when circumstances permit
- Sitting and talking with someone
- Sitting quietly after lunch without alcohol
- In a car, while stopped for a few minutes in traffic
The patient rates their likelihood of falling asleep in these 8 different situations as: 0 (would never doze), 1 (slight chance of dozing), 2 (moderate chance of dozing), or 3 (high chance of dozing). The maximum score is 24, and a score of 10 or below is considered normal. Daytime sleepiness may also be measured objectively with tests such as the multiple sleep latency test or the maintenance of wakefulness test.
Daytime sleepiness is uncommon in young children with OSA. Symptoms in children may include habitual snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems. OSA can occur in children of all ages, from neonates to adolescents. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders. In otherwise healthy children, OSA is usually associated with adenotonsillar hypertrophy and/or obesity. The first-line treatment for pediatric OSA is adenotonsillectomy.
The final diagnosis of OSA rests on a combination of clinical evaluation and objective criteria to identify those levels of obstruction that are considered to be clinically significant.
Medical management of OSA includes weight loss; avoiding consumption of alcohol and sedatives prior to bedtime; oral appliances, and various types of CPAP (i.e., fixed CPAP, bi-level positive airway pressure [BiPAP], or auto-adjusting CPAP [APAP]). CPAP involves the administration of air, usually through the nose, by an external device at a fixed pressure to maintain the patency of the upper airway. BiPAP is similar to CPAP, but these devices are capable of generating 2 adjustable pressure levels. APAP adjusts the level of pressure based on the level of resistance, and thus administers a lower mean level of positive pressure during the night. It has been hypothesized that both BiPAP and APAP are more comfortable for the patient, and thus might improve patient compliance or acceptance. Oral appliances can be broadly categorized as mandibular advancing/positioning devices or tongue-retaining devices. Oral appliances can either be “off the shelf” or custom made for the patient by a dental laboratory or similar provider.
The use of atrial overdrive pacing is also being evaluated in the treatment of obstructive sleep apnea. This approach is being tried because of the bradycardia that generally occurs during episodes of apnea.
See related policies:
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Prior Approval:
Not applicable
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Policy:
Initial Studies
Supervised polysomnography performed in a sleep laboratory may be considered medically necessary as a diagnostic test in patients with any of the following:
- Observed apneas during sleep;
OR
- A combination of at least two of the following:
- Excessive daytime sleepiness evidenced by an Epworth Sleepiness Scale greater than 10, inappropriate daytime napping (e.g., during driving, conversion, or eating), or sleepiness that interferes with daily activities and is not explained by other conditions, (this may be expressed as learning difficulties or other daytime neurobehavioral problems in young children);
- Habitual snoring, or gasping/choking episodes associated with awakenings;
- Unexplained hypertension;
- Obesity, defined as a body mass index greater than 35 kg/m2 in adults or greater than the 90th percentile for the weight/height ratio in pediatric patients;
- Craniofacial or upper airway soft tissue abnormalities, including adenotonsillar hypertrophy, or neuromuscular disease.
OR
- Moderate or severe congestive heart failure, stroke/transient ischemic attack, coronary artery disease, or significant tachycardia or bradycardic arrhythmias in patients who have nocturnal symptoms suggestive of a sleep-related breathing disorder or otherwise are suspected of having sleep apnea.
A split-night in-laboratory polysomnography in which the initial diagnostic portion of the polysomnography is followed by positive airway pressure (PAP) titration may be considered medically necessary when EITHER of the following criteria is met:
- Apnea/hypopnea index (AHI) of 40/hr or higher during the initial diagnostic portion of the split-night study
- AHI of 20-40/hr with symptoms indicative of significant OSA (e.g., repetitive obstructions and significant oxygen desaturations)
Unattended (unsupervised) home sleep studies with a minimum of 4 recording channels (including oxygen saturation, respiratory movement, airflow, and EKG or heart rate) may be considered medically necessary in adult patients who are at high risk for obstructive sleep apnea (OSA). Patients considered high risk must have all the following symptoms:
- Habitual snoring
- Observed apneas
- Excessive daytime sleepiness, and
- A body mass index greater than 35
In addition, those patients eligible for an unattended study must have no evidence, by history or physical examination, of any of the following conditions as they might alter ventilation or require alternative treatment:
- Central sleep apnea
- Congestive heart failure
- Chronic pulmonary disease
- Obesity hypoventilation syndrome
- Narcolepsy
- Periodic limb movements in sleep
- Restless leg syndrome
Unattended (unsupervised) sleep studies are considered investigational in adult patients who are considered at low to moderate risk for OSA.
Unattended (unsupervised) sleep studies are considered investigational in pediatric patients (i.e., less than 18 years of age).
Repeated Studies
A repeated supervised polysomnography performed in a sleep laboratory may be considered medically necessary under any of the following circumstances due to a substantial change in symptoms:
- To initiate and titrate continuous positive airway pressure (CPAP) in adult patients with clinically significant OSA defined as those patients who have:
- An apnea/hypopnea index (AHI) of at least 15 per hour; OR
- An AHI of at least 5 per hour in a patient with excessive daytime sleepiness or unexplained hypertension.
Notes:
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- Failure of resolution of symptoms or recurrence of symptoms during treatment.
- To assess efficacy of surgery (including adenotonsillectomy) or oral appliances/devices.
- To Re-evaluate the diagnosis of OSA and need for continued CPAP, e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be retitrated or possibly discontinued.
Note: This statement does not imply that supervised studies are needed routinely following unattended studies. This statement means a re-evaluation based on a substantial change in symptoms or in the clinical situation.
Repeated unattended (unsupervised) home sleep studies with a minimum of four recording channels (including oxygen saturation, respiratory movement, airflow, and EKG/heart rate) may be considered medically necessary in adult patients under the following circumstances:
- To assess efficacy of surgery or oral appliances/devices; OR
- To re-evaluate the diagnosis of OSA and need for continued CPAP, e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be re-titrated or possibly discontinued.
Multiple sleep latency testing (MSLT) is considered not medically necessary in the diagnosis of obstructive sleep apnea syndrome except to exclude or confirm narcolepsy in the diagnostic workup of OSA syndrome.
Medical Management
Continuous positive airway pressure (CPAP) may be considered medically necessary in adult or pediatric patients with clinically significant obstructive sleep apnea.
Bi-level positive airway pressure (BiPAP) or auto-adjusting CPAP (APAP) may be considered medically necessary in patients with clinically significant obstructive sleep apnea AND who have failed a prior trial of CPAP.
Oral appliances: Intraoral appliances may be considered medically necessary in patients with clinically significant obstructive sleep apnea, as defined above using AHI. Intraoral appliances include either tongue-retaining devices or mandibular advancing/positioning devices.
Atrial pacing is considered investigational in the treatment of obstructive sleep apnea.
The following tests and treatments for OSA and UARS are considered investigational:
- Topographic EEG
- Actigraphy
- Cephalometric High Speed Sleep Studies
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
Report MSLT with CPT code:
- 95805; Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
Report attended sleep studies with the following CPT codes:
- 95807; Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
- 95808; Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist
- 95810; Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist
- 95811; Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
Report unattended sleep studies with CPT code:
- 95800; Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time
- 95801; Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
- 95806; Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement)
Report HCPCS codes for home sleep test with portable monitors, unattended:
- G0398; Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
- G0399; Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
- G0400; Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
Report CPAP with the following codes:
- 94660; Continuous positive airway pressure ventilation (CPAP), initiation and management
- E0601; Continuous airway pressure (CPAP) device
Report the BiPAP device with HCPCS codes:
- E0470; Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) , or
- E0471; Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
- E0472; Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
Report oral device/appliance used to reduce upper airway collapsibility using HCPCS codes:
- E0485; Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustmen
- E0486; Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment
- S8040; Topographic brain mapping
- 95803; Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) 95803 will be denied because it does not meet coverage criteria.
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Selected References:
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The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
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A review of the medical literature and recommendations from the Medical Policy Advisory Council (MPAC), which assists Wellmark’s medical directors in the development of medical policies. MPAC is comprised of practicing physicians from Iowa and South Dakota.
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Loube DI, Andrada T, Shanmagum N, Singer MT. Successful treatment of upper airway resistance syndrome with an oral appliance. Case Report by Daniel I Louge MD, FCCP Sleep Disorder Center, Pulmonary/Critical Care Medicine Service, Walter Reed Army Medical Center, Washington DC. Revised Nov. 10th 1997.
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Schoem SR. Review Article: Oral appliances for the treatment of snoring and obstructive sleep apnea. Otolaryngology Head and Neck Surgery 2000; 122:259-262.
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Gagnadoux F, Pelletier-Fleury N, et al. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002 Mar;121(3):753-8.
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Luthje L, Unterberg-Buchwald C, Dajani D, Vollmann D, Hasenfuss G, Andreas S. Atrial overdrive pacing in patients with sleep apnea with implanted pacemaker. Am J Respir Crit Care Med. 2005 Jul 1;172(1):118-22.
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Luthje L, Unterberg-Buchwald C, Dajani D, Vollmann D, Hasenfuss G, Andreas S. Atrial overdrive pacing in patients with sleep apnea with implanted pacemaker. Am J Respir Crit Care Med. 2005 Jul 1;172(1):118-22.
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Ayappa I, Norman RG, et al. Comparison of limited monitoring using a nasal-cannula flow signal to full polysomnography in sleep-disordered breathing. Sleep. 2004 Sep 15;27(6):1171-9.
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ECRI. Actigraphy for the Evaluation of Sleep Disorders. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005 March 9. 9 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Liesching TN, Carlisle C, et al. Evaluation of the Accuracy of SNAP Technology Sleep Sonography in Detecting Obstructive Sleep Apnea in Adults Compared to Standard Polysomnography. Chest. 2004 Mar;125(3):886-91.
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Hailey D, Tran K, et al. A review of guidelines for referral of patients to sleep laboratories [Technology report no 55]. Ottawa: Canadian Coordinating Office for Health Technology Assessment; 2005.
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Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman J, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Accessed Nov 12, 2008. Available at URL address: http://www.aasmnet.org/PracticeParameters.aspx?cid=104
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Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea in adults. Health Care Guideline. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 2008 Jun. 55p. Available at the ICSI Web site. Accessed October 12, 2008.
- Epstein LJ, Kristo D, trollo PJ Jr. Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, SchwabRJ, Weaver EM, Weinsteing MD; Adult Obstructive Sleep Apnea Task Force fo the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun 15:5(3)263-76.
- ECRI Institute. Ambulatory/Portable Sleep Apnea Monitors for Diagnosis of Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI Institute; 2009 Oct 20. 12 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- ECRI Institute. Auto-titrating Continuous Positive Airway Pressure (Auto-CPAP) versus Fixed Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI Institute; 2009 Nov 03. 9 p. [ECRI hotline response]. Also available: http://www.ecri.org
- ECRI Institute. Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS). Plymouth Meeting (PA): ECRI Institute; 2010 Jan 07. 13 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- Morganthaler T, Kapen S, Lee-Chiong T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006 Mar 9; 29(8): 1031-1035.
- Skomro R, Gjevre J, Reid J, et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest. 2010 Aug; 138(2): 257-263
- Mulgrew A, Fox N, Ayas N, et al. Diagnosis and initial management of obstructive sleep apnea without polysomnography. Ann Intern Med. 2007; 146(3): 157-166.
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Policy History:
Date Reason Action
July 2011 Annual review Policy revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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