Sleep Apnea and Upper Airway Resistance Syndrome* Printer-Friendly Version   

Medical Policy: 07.01.21 
Original Effective Date: January 2001 
Reviewed: January 2008 
Revised: March 2007 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description: 

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 causes excessive daytime sleepiness that can lead to impairment of almost any 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. In addition, excessive daytime sleepiness indirectly 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 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.

The following tests are available to diagnose these conditions:

• Polysomnography: When performed under the supervision of a trained technologist in a hospital outpatient or free standing certified sleep lab. A standard polysomnography includes an EEG to stage sleep and detect arousal events, an electro-oculography to detect arousals and REM sleep and a submental electromyogram. Additional parameters that may be measured include respiratory monitoring with plethysmography of the chest, a single lead ECG, ear or pulse oximetry, gastroesophageal reflux, continuous blood pressure monitoring, snoring volume and electromyographic monitoring of leg movements.  Polysomnographs are scored according to how many times per hour patients stop breathing (apneic) or almost stop breathing (hypopneic). The final scores are called the Respiratory Disturbance Index (RDI) or the Apnea-Hypopnea Index (AHI). (The apnea-hypopnea index (AHI) is an index of severity that combines apneas and hypopneas. Combining them both gives an overall severity of sleep apnea including sleep disruptions and desaturations (a low level of oxygen in the blood). The apnea-hypopnea index, like the apnea index and hypopnea index, is calculated by dividing the number of apneas and hypopneas by the number of hours of sleep. Another index that is used to measure sleep apnea is the respiratory disturbance index (RDI). The respiratory disturbance index is similar to the apnea-hypopnea index, however, it also includes respiratory events that do not technically meet the definitions of apneas or hypopneas, but do disrupt sleep). The AHI must be based on a minimum of two hours of recorded sleep time without the use of CPAP. 
• Multiple sleep latency test (MSLT): Used to measure how quickly the patient falls asleep in a non-stimulating environment. While this test is not typically used to evaluate sleep apnea, it may be used when excessive daytime sleepiness suggests narcolepsy or other sleep disorders are suspected and polysomnography has not been adequate for diagnosis.
• Portable sleep studies or unattended sleep studies: These are conducted in the home or other setting, without supervision of a trained technologist.
• Maintenance of wakefulness test (MWT): Used as a follow up test for sleep disorders to assess patient sleepiness on the day following polysomnography. This test is also sometimes used to rule out narcolepsy.
• SNAP® Test: A type of unsupervised sleep study marketed by SNAP Laboratories, L.L.C. This is a test using a proprietary digital recorder about the size of a laptop computer. It is taken home from the provider’s office by the patient and is used without the supervision of a trained technician.
• Topographic EEG mapping: A machine measures brain waves and draws a type of map of the brain.
• Actigraphy is a technique used in research studies for the evaluation of sleep-rest cycles. It measures the extent of motor activity of the patient during sleep.  

The following treatments of OSA and UARS are available:

Medical treatment:

• CPAP (continuous positive airway pressure) devices are considered the first line of treatment. BiPAP (bilevel positive airway pressure), and DPAP (demand positive airway pressure) are alternative devices that may be used for some patients who do not tolerate treatment with CPAP.
• Intra-oral appliances include tongue-retaining devices and mandibular advancing or repositioning devices.
• Weight loss: A reduction in weight has been shown to substantially reduce the incidence of sleep apnea.

Surgical treatments:

• Uvulopalatopharyngoplasty (UPPP)
• Hyoid Suspension, surgical modification of the tongue, and /or maxillofacial surgery, including mandibular-maxillary advancement (MMA)
• Laser-assisted uvulopalatoplasty (LAUP)
• Radiofrequency volumetric tissue reduction (Somnoplasty™)
• Tongue base suspension; soft tissue to bone suspension (Repose System™)

• Cautery assisted palatal stiffening operation (CAPSO)

• Palatal restoration with implants (The Pillar® Palatal Implant System)

• Tracheotomy

Policy: 

• A supervised polysomnography or sleep study performed in a sleep laboratory may be considered medically necessary for patients with pronounced snoring or restlessness with any one of the following conditions:
  • Witnessed apneic events while sleeping
  • Excessive daytime sleepiness or
  • Unexplained hypertension or arrhythmia
• A repeat supervised polysomnography or sleep study performed in a sleep laboratory may be considered medically necessary for patients with weight change or change in symptoms suggesting that CPAP should be retitrated or perhaps discontinued.
• CPAP may be considered a medically necessary treatment for patients with clinically significant OSA, defined as meeting any of the following criteria:
  • An AHI equal to or greater than 15 or
  • An AHI between 5 and 14 with any of the following associated symptoms:
    • Excessive daytime sleepiness
    • Impaired cognition
    • Mood disorders
    • Insomnia
    • Documented Hypertension
    • Ischemic heart disease or
    • History of stroke
• BiPAP or DPAP may be considered medically necessary in patients with clinically significant OSA (See OSA criteria above) who have failed a trial of CPAP.

• Oral appliances:  Prior Approval is recommended to document medical necessity. Submit a prior approval now.

• UPPP: Prior Approval is recommended to document medical necessity. Submit a prior approval now.

• MMA: May be considered medically necessary for a patient with hypopharyngeal obstruction who has failed a trial of CPAP.

• MWT: May be considered medically necessary as a follow up test for the treatment of sleep disorders to assess patient alertness.

• MSLT: may be considered medically necessary to rule out or confirm narcolepsy or other sleep disorders when polysomnography has not been conclusive.

The following documentation may be used to support the  Prior Approval of oral appliances or UPPP as treatments of OSA or UARS:

• Polysomnography in an attended sleep lab and documentation of any of the following symptoms; excessive daytime sleepiness, narcolepsy, nocturnal myoclonia, insomnia or parasomnia.
• CPAP trial for patients who have undergone an attended polysomnography with an AHI of 15 or more, or an AHI of between 5 and 14 with one or more of the following associated symptoms:
  • Excessive daytime sleepiness
  • Impaired cognition
  • Mood disorders
  • Insomnia
  • Documented Hypertension
  • Ischemic heart disease or
  • History of stroke
• A trial of CPAP may also be considered medically necessary for patients who do not have OSA but who have UARS as documented by >10 alpha EEG arousals per hour, or for patients with abnormally negative intrathoracic pressures (i.e. >10cm H2O) in conjunction with >10 EEG arousals per hour prior to approval of treatment with oral applicances or UPPP.

The following tests and treatments for OSA and UARS are not covered benefits because they are considered investigational:

• Portable sleep apnea studies or portable sleep apnea screening devices (Also known as unattended sleep studies)
• Snap® Test (A proprietary unattended sleep study)
• Topographic EEG
• Actigraphy 
• Cephalometric High Speed Sleep Studies
• LAUP: Not medically necessary for snoring and investigational for OSA
• Radiofrequency volumetric tissue reduction (Somnoplasty™)
• Cautery assisted palatal stiffening operation (CAPSO)
• Palatal restoration with implants (The Pillar® Palatal Implant System)
• Repose System

MSLT is considered not medically necessary for the diagnosis of obstructive sleep apnea.  

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• 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
• CPT code 95806 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist
• CPT code 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
• CPT code 95808 Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist
• CPT code 95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist
• CPT code 95811 Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist
• CPT code 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management
• CPT code 42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)
• CPT code 21199 Osteotomy, mandible, segmental; with genioglossus advancement
• CPT code 0088T Submucosal radiofrequency tissue volume reduction of tongue base, one or more sites, per session (ie, for treatment of obstructive sleep apnea syndrome)
• CPT code 42299 Unlisted procedure, palate, uvula
• HCPCS code S2080 Laser-assisted uvulopalatoplasty (LAUP)
• HCPCS code S8040 Topographic brain mapping
• HCPCS code E0601 Continuous airway pressure (CPAP) device
• HCPCS code 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)
• HCPCS code 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)
• HCPCS code E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment
• HCPCS code E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment
• HCPCS code 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
• HCPCS code 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
• HCPCS code G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels        

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Selected References: 

• 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.
• Mair EA, Day RH. Cautery-assisted palatal stiffening operation. Otolaryngology Head and Neck Surgery 2000; 122:547-555.
• DeRowe A, Gunther E, et al. Tongue-based suspension with a soft tissue to bone anchor for obstructive sleep apnea: Preliminary clinical results of a new minimally invasive technique. Otolaryngology Head and Neck Surgery 2000; 122:100-103. 
• Woodson BT. Surgical approaches to obstructive sleep apnea. Current Opinion in Pulmonary Medicine 1998;4:344-350.
• Schoem SR. Review Article: Oral appliances for the treatment of snoring and obstructive sleep apnea. Otolaryngology Head and Neck Surgery 2000; 122:259-262.
• 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.
• Luthje L, Unterberg-Buchwald C, Dajani 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.
• Pepin JL, Defaye P, et al. Overdrive atrial pacing does not improve obstructive sleep apnea syndrome. Eur Respir J. 2005 Feb; 25(2):343-7.
• 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.
• ECRI. Actigraphy for the Evaluation of Sleep Disorders. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005 March 9. 9p. (ECRI Hotline Response). Also available: http//www.ecri.org.
• 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.
• 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.
• Fukuse T, Satoda N, Hijiya K, Fujinaga T. Importance of a comprehensive geriatric assessment in predication of complications following thoracic surgery in elderly patients. Chest. 2005 Mar;127(3):886-91. 

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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309

*Prior Approval is recommended for this policy.

**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.