Medical Policy: 07.01.21 

Original Effective Date: January 2001 

Reviewed: March 2017 

Revised: June 2017 

 

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. The patient is usually unware of it and sometimes may awaken gasping for breath. In patients with OSA, the normal pharyngeal narrowing is accentuated by anatomic factors, such as a short, wide neck, elongated palate and uvula, or large tonsillar pillars with redundant lateral pharyngeal wall mucosa. The diagnosis of OSA involves measuring breathing during sleep, and is typically diagnosed by overnight monitoring with polysomnography (PSG) (sleep study).

 

The hallmark clinical symptom of OSA is excessive daytime sleepiness; the hallmark clinical sign is snoring. With 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 the repeated arousal during sleep can lead to impairment of daytime activity. Adult patients with OSA and associated daytime somnolence are thought to be a higher risk for accidents involving motorized vehicles or heavy equipment. In addition, OSA affects the cardiovascular and pulmonary systems. For example, apnea leads to periods of hypoxemia, alveolar hypoventilation, hypercapnia and acidosis. This in turn can cause systemic hypertension, cardiac arrhythmias, pulmonary hypertension 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. 

 

In adults, OSA is often suspected on the basis of the clinical history and physical appearance. The presence or absence and severity of OSA must be determined before initiating treatment. The diagnostic criteria is based on clinical signs and symptoms determined during a comprehensive sleep evaluation, which includes a sleep oriented history and physical examination and findings identified by sleep testing (polysomnography). 

 

Excessive daytime sleepiness may be subjective and may be assessed by questionnaires (e.g. Epworth Sleepiness Scale, Berlin Questionnaire, STOP Questionnaire and STOP-BANG Questionnaire).  

 

The Epworth Sleepiness Scale (ESS), 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?”

  1. Sitting and reading
  2. Watching TV
  3. Sitting inactive in a public place, ie, theater
  4. As a passenger in a car for 1 hour without a break
  5. Lying down to rest in the afternoon when circumstances permit. 
  6. Sitting and talking with someone
  7. Sitting quietly after lunch without alcohol
  8. In a car, while stopped for a few minutes in traffic

The patient rates his or her 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.

 

The STOP-BANG questionnaire is an OSA screening tool consisting of four yes/no questions and four clinical attributes that incorporates information on the signs and symptoms of OSA that includes snoring, tiredness, observed apneas, blood pressure, BMI, age, neck circumference and gender.  The Berlin questionnaire consists of eleven questions divided into three categories to classify the patient as high or low risk for OSA. The STOP questionnaire consists of four yes/no questions to assess signs and symptoms of OSA.

 

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. The gold standard diagnostic test for sleep disorders is considered a polysomnogram (sleep study), which can be done in an accredited facility or sleep laboratory or in the home.

 

Supervised Facility or Laboratory Sleep Study (Polysomnography)

A facility based sleep study (polysomnography (PSG)) is conducted in an accredited facility or sleep laboratory site and requires an overnight stay.  PSG is designed to capture multiple sensory channels including blood pressure, brain waves, breathing patterns and heartbeat as  an individual sleeps. It can also record eye and leg movements and muscle tension which can be useful in diagnosing parasomnias. A PSG performed at a facility or sleep laboratory will record a minimum of 12 channels which involves at least 22 wire attachments to the individual. Sensors that send electrical signals to a computer are placed on the chest, face, head and legs. The test is attended by a technologist and the results are evaluated by a qualified sleep physician. A PSG may be performed in conjunction with positive airway pressure (PAP) machine to determine the titration of oxygen flow.   

 

By definition, a polysomnogram always includes sleep staging. The three elements EEG, chin electromyogram and electro-oculogram (EOG) are required for sleep staging.   Sleep staging is performed to assess arousals from sleep, and determination of the frequency of apneas and hypopneas from channels measuring oxygen desaturation, respiratory airflow and respiratory effort. The actual components of the study will be dictated by the clinical situation. 

 

Per the American Academy of Sleep Medicine (AASM) guidelines a facility based polysomnography (sleep study) is recommended rather than home sleep study for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. In this population of patients a facility based sleep study is considered the gold standard method for the diagnosis of OSA. Home based sleep studies have not been adequately validated or demonstrated to provide favorable clinical outcomes and efficient care in the above patient population, which may result in harm through inaccurate assessment of sleep disordered breathing. Facility based PSG are not appropriate for general screening of asymptomatic populations. 

 

A facility or sleep laboratory-based PSG may also be indicated when a home sleep study (portable monitoring) is technically inadequate or fails to establish the diagnosis in an individual with a high pretest probability of OSA.

 

Unsupervised (Unattended) Home Sleep Study

Unsupervised (unattended) home sleep study and PAP titration is an alternative to an accredited facility or sleep laboratory based sleep disorder testing to diagnose obstructive sleep apnea (OSA). There may be limited access to in-laboratory (facility based) testing in some areas. This may also be considered a more cost effective setting, which is often more comfortable and convenient for the individual and a more efficient way of testing a certain adult patient population. Based on the American Academy of Sleep Medicine guidelines regarding diagnostic testing for adult OSA, home sleep apnea testing with a technically adequate device may be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.  An increased risk of moderate to severe OSA is indicated by the presence of excessive daytime sleepiness and at least two of the following: habitual loud snoring, witnessed apnea or gasping or choking, or diagnosed hypertension.

 

Based on clinical guidelines on the use of home sleep studies (unsupervised/unattended) for the diagnosis of obstructive sleep apnea (OSA) in adults by the American Academy of Sleep Medicine (AASM), the study should be performed only in conjunction with a comprehensive sleep evaluation and used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. AASM defines an uncomplicated patient by the absence of the following: conditions that place the patient at increased risk of non-obstructive sleep disordered breathing (e.g. central sleep apnea, hypoventilation and sleep related hypoxemia): examples of these conditions include significant cardiopulmonary disease, potential respiratory muscle weakness due to neuromuscular conditions, history of stroke or chronic opiate medication use; concern for significant non-respiratory sleep disorder(s) that require evaluation (e.g. disorders of hypersomnolence, parasomnias, sleep related movement disorders) or interfere with accuracy of home sleep studies (e.g. severe insomnia); environmental or personal factors that preclude the adequate acquisition and interpretation of data. A technically adequate diagnostic test includes a minimum of 4 hours of technically adequate oximetry and flow data obtained during a recording attempt that encompasses the habitual sleep period.  Also, home sleep studies are not appropriate for general screening of asymptomatic populations.

 

Home based sleep testing utilizes portable monitoring (PM) FDA approved devices that are designed to be used by an individual without supervision of a sleep technologist. Provision of the device, patient instruction, and support can be provided by sleep centers, professional providers, and/or independent diagnostic testing facilities that can demonstrate how to use FDA approved devices, inspect the devices and administer patient education. The patient applies the sensors as instructed to the body before sleep time and sleeps with the equipment. The equipment is returned to the diagnostic service provider/company where the data is downloaded and processed for interpretation by a sleep physician.  Home based sleep testing portable monitoring devices measure fewer parameters than a laboratory based sleep study and per the American Academy of Sleep Medicine a technically adequate home sleep testing device incorporates a minimum of the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry. 

 

Traditionally sleep studies have been categorized as Type I, Type II, Type III or Type IV (see below sleep monitoring devices). Unattended/home based sleep studies fall into categories Type II through Type IV. Type II studies use the same monitoring sensors as full polysomnography (Type I). Type III studies use devices that measure limited cardiopulmonary parameters; two respiratory variables (e.g. effort to breathe, airflow), oxygen saturation and a cardiac variable (e.g. heart rate or electrocardiogram). Type IV studies utilize devices that measure only 1 or 2 parameters, typically oxygen saturation and heart rate, or in some cases just air flow. A home based study is conducted over at least one night.

 

 

 

Sleep Monitoring Devices
Type I Comprehensive Standard Overnight polysomnography in a sleep center or laboratory with a sleep technician in constant attendance. Minimum of 7 channels including EEG, EOG, chin EMG, ECG or heart rate, airflow, respiratory effort, oxygen saturation
Type II Home sleep test (HST) type II portable monitor, unattended

Minimum of 7 channels including EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation

Type III

Home sleep test (HST) type III portable monitor, unattended

Minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation

Type IV (A) Home sleep test (HST) type IV portable monitor; three or more bioparameters

Airflow and at least 2 other parameters (e.g. EOG, peripheral arterial tonometry (PAT), snoring or pulse oximetry)

 

Type IV (B)

Home sleep test (HST) type IV portable monitor; continuous single or dual bioparameter recording

Minimum of 1 parameter (e.g. overnight oximetry)

 

Note: Guidelines indicate that nocturnal pulse oximetry alone is not appropriately used as a case finding or screening method for OSA. Pulse oximetry, when used alone, has not been shown to have an adequate predictive value to rule out OSA. All patients with symptoms suggestive of OSA would require polysomnography regardless of whether the pulse oximetry was positive or negative.

 

When a diagnosis of OSA is established following a home study, home titration to determine a fixed PAP pressure can be effectively completed using auto-titrating positive airway pressure (APAP). Evidence from several well-designed trials demonstrates that home PAP titration using APAP compared to in-facility titration results in similar outcomes in terms of improvement in AHI, Epworth Sleepiness scores, and CPAP acceptance and adherence.

 

APAP devices deliver variable pressure according to the needs of the patient. When an obstructive event is detected, an APAP device will increase pressure until the event is eliminated. If no further events are detected during a set time period, the device will decrease pressure to a pre-set minimum. APAP devices may use combinations of physiologic signals to detect airflow obstruction, including snoring, flow or impedance. Because the minimum pressure required to keep the airway open is used, the mean pressure applied throughout the night is reduced. This reduction in mean pressure may improve tolerance in some patients, resulting in improved adherence with the use of PAP.

 

Per the American Academy of Sleep Medicine practice parameters for use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007, the recommendations include that certain APAP devices may be used in an unattended way to determine fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndrome, or hypoventilation syndromes).

 

There is adequate evidence to demonstrate that portable monitoring/home sleep apnea studies accurately predict AHI suggestive of OSA with high positive likelihood ratios and low negative likelihood ratios in patients with a high pretest probability of OSA. Comparative effectiveness studies that have evaluated clinical outcomes of patients managed with home testing vs. those managed with facility/sleep laboratory PSG and demonstrated similar outcomes in terms of functional improvement (e.g., sleepiness scores, activity level, vigilance, productivity), and CPAP adherence.

 

Diagnosis of Obstructive Sleep Apnea

Apnea is defined as the cessation of airflow for at least 10 seconds. 

 

Based on 2013 clarification by the American Academy of Sleep Medicine (AASM) the recommendation for hypopnea scoring criteria is the following:

  • The peak single excursions drop by ≥  30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study), or an alternative hypopnea sensor (diagnostic study).
  • The duration of the ≥ 30%  drop in signal excursion is ≥ 10 seconds.
  • There is a ≥ 3%  oxygen desaturation from pre-event baseline and/or the event is associated with an arousal; OR There is a ≥ 4%  oxygen saturation from pre-event baseline.   

The apnea-hypopnea index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour of sleep without the use of positive airway pressure device. Sleep time can only be measured in a Type I (facility based polysomnogram) or Type II sleep study. The AHI is reported only in Type I or Type II sleep studies. 

 

The respiratory disturbance  index (RDI) is equal to the episodes of apnea and hypopnea per hour of recording without the use of a positive airway pressure device. The RDI is reported in Type III and Type IV sleep studies.

 

A full night polysomnography (PSG) is recommended for the diagnosis of sleep related breathing disorder, but a split-night study (initial diagnostic PSG followed by continuous positive airway pressure titration on the same night) is an alternative to one full night of diagnostic PSG. The split-night study may be performed if an apnea/ hypopnea index (AHI) 40/hour is documented during a minimum of 2 hours of a diagnostic study but may be considered for an AHI of 20-40/hour based on clinical judgement.  Also, there needs to be at least 3 hours available for PAP titration.    

 

The diagnosis of OSA is confirmed if the number of obstructive events (apneas, hypopneas + respiratory event related arousals) on PSG is greater than 15 events/hour or greater than 5/hour in a patient who reports any of the following: unintentional sleep episodes during wakefulness; daytime sleepiness; unrefreshing sleep; fatigue; insomnia; waking up breath holding, gasping or choking; or the bed partner describing loud snoring, breathing interruptions, or both during the patients sleep. 

 

OSA Severity:

  • An AHI ≥ 15 is typically considered moderate OSA
  • An AHI greater than 30 is considered severe OSA
  • An RDI ≥ 5 and ≤ 15 is considered mild OSA
  • An RDI ≥ 15 and ≤ 30 is considered moderate OSA
  • An RDI > 30/hour is considered severe OSA   

 

Specialist Training

The medical professional who is interpreting a supervised sleep study or home sleep study should have training in sleep medicine and should review the raw data from PSG and home sleep studies in order to detect artifacts and data loss. In addition, the treatment of patients diagnosed with OSA should be initiated and monitored by a professional with training in sleep medicine. It is important to monitor symptoms and adherence to positive airway pressure (PAP) treatment.

 

Medical Management

Medical management of OSA includes: 

  • Weight loss
  • Avoiding consumption of alcohol and sedatives prior to bedtime
  • Oral appliances
  • Various types of CPAP (i.e., fixed CPAP, bi-level positive airway pressure [BPAP], or auto-adjusting CPAP [APAP])
  • Surgical treatment

 

Multiple Sleep Latency Testing (MSLT)

The multiple sleep latency test (MSLT) involves multiple trials (4 to 5 times) during a day to objectively assess sleep tendency by measuring the number of minutes it takes the patient to fall asleep.

 

The MSLT records whether the patient falls asleep during the test and what types and stages of sleep the patient is having. The MSLT is the better test for demonstration of sleep onset rapid of eye movement (REM) periods. The types and stages of sleep during the day can help establish the diagnosis of narcolepsy and idiopathic hypersomnia.

 

According to American Academy of Sleep Medicine (AASM), the MSLT is indicated as part of the evaluation of patients with suspected narcolepsy to confirm the diagnosis, and for patients with suspected idiopathic hypersomnia to help differentiate idiopathic hypersomnia from narcolepsy. The MSLT is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea or in assessment of change following treatment with nasal CPAP. The MSLT is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy and idiopathic hypersomnia), insomnia, or circadian rhythm disorders.

 

Additional Diagnostic Tests for Obstructive Sleep Apnea (OSA)

Actigraphy 

Actigraphy refers to the assessment of activity patterns (body movement) using devices typically placed on the wrist or ankle that are interpreted by computer algorithms as periods of sleep (absence of activity) and wake (activity).  Actigraphy devices are typically placed on the nondominate wrist with wristband and are worn continuously for at least 24 hours. Activity is usually recorded for a period of 3 days to 2 weeks but can be collected continuously over extended time periods with regular downloading of data onto a computer. The activity monitors may also be placed on the ankle for the assessment of restless leg syndrome.

 

The algorithms for detection of movement are variable among devices. Data on patient bed times (lights out) and rise times (lights on) are usually entered into the computer record from daily patient sleep logs or by patient activated event markers. Proprietary software is then used to calculate periods of sleep based on the absence of detectable movement, along with movement related to level of activity and periods of wake. In addition to providing graphic depiction of the activity pattern, device specific software may analyze and report a variety of sleep parameters including sleep onset, sleep offset, sleep latency, total sleep duration and wake after sleep onset.  Actigraphy might also be used to measure the level of physical activity.

 

Actigraphy has been used for more than 2 decades as an outcome measure in sleep disorder research. For clinical applications, actigraphy is being evaluated as a measure of sleep-wake cycles in sleep disorders, including insomnia and circadian rhythm sleep disorders. In addition, actigraphy is being investigated as a measure of sleep-wake disturbances associated with numerous diseases and disorders.

 

Updated practice parameters in 2007 by American Academy of Sleep Medicine (AASM) on the use of actigraphy in the assessment of sleep and sleep disorders recommended actigraphy as a “standard” only as a method to estimate total sleep time in patients with obstructive sleep apnea syndrome when polysomnography (PSG) is not available.  Other indications changed from “option” to “guideline” but failed to reach a recommendation of “standard” due primarily to the absence of high-quality trials. Few studies provided technical details related to the administration and scoring of actigraphy. In addition, most studies lacked descriptions of blinding, and there was “an inadequate description of whether visual inspection of data is performed, how missing data is handled, and other important decisions made in the analysis of actigraphy data.” AASM indicated the need for additional research in the following areas:

  • Comparison of “results from different actigraphy devices and the variety of algorithms used”
  • “Standards for setting and stop times”
  • “Reliability and validity, compared with reference standards”
  • Clarification of “the relative and unique contributions of actigraphy, polysomnography and sleep logs in the diagnosis of sleep disorders and measurement of treatment effects” 

For individuals who have circadian sleep-wake rhythm disorders, central disorders of hypersomnolence, or insomnia who receive actigraphy, the evidence includes prospective and retrospective validation studies. The clinical validity of actigraphy depends, to a large extent, on the modality for which it is being compared. Comparisons with sleep diaries have shown reasonable correlations for measures of bedtime, sleep onset, and wake time in adults. The relative and unique contributions of actigraphy and sleep logs in the diagnosis of sleep disorders and measurement of treatment effects remain to be demonstrated. Comparisons with the more resource-intensive polysomnography or behavioral scoring have indicated that actigraphy has sufficient sensitivity to detect sleep but has poor specificity distinguishing between wake and sleep. The literature has also shown that the accuracy of actigraphy for differentiating between wake and sleep decreases as the level of sleep disturbance increases.  Overall, progress has been made since 2007 American Academy of Sleep Medicine (AASM) research recommendations in comparing the reliability and the validity of different algorithms with the reference standard. Although actigraphy appears to provide reliable measures of sleep onset and wake time in some patient populations, its clinical utility over sleep diaries has not been demonstrated. Moreover, evidence has shown that actigraphy does not provide a reliable measure of sleep efficiency in clinical populations. The evidence to date does not indicate that this technology is as beneficial as the established alternatives and is insufficient to determine the effects on net health outcomes.

 

SleepStrip™

The SleepStrip is an OSA screening device that incorporates signal detection, acquisition and display in a disposable package. The self-adhesive device is placed on the upper lip at bedtime and adjusted until respiration is detected, as indicated by a flashing light. Two nasal thermistors and one oral thermistor produce flow signals that are processed within the SleepStrip’s microprocessor (CPU). The five possible results are as follows: zero (no apneas); one (mild sleep apnea, comparable to sleep lab AHI between 15 and 24); two (moderate sleep apnea, comparable to sleep lab AHI between 25 and 39); three (severe sleep apnea, comparable to sleep lab AHI of greater than 40); and E (error in measurement).

 

SleepStrip has a low correlation with the AHI as measured by PSG, and further studies are needed before this device can be recommended as a screening tool for the diagnosis of OSA.  The evidence is insufficient to determine the effects on net health outcomes.

 

PAP-Nap Study

An abbreviated cardiorespiratory sleep study, referred to as a PAP-nap study, has been proposed as a method to acclimate patients to PAP and promote adherence to therapy. The PAP-nap study includes mask and pressure desensitization and therapy to overcome aversive emotional reactions, mental imagery, and physiologic exposure to PAP therapy during a nap period. There is insufficient evidence in the published medical literature to determine whether PAP-nap studies result in improved adherence to therapy and is insufficient to determine the effects on net health outcomes.

 

Topographic EEG

Topographic brain mapping has been briefly described in the evaluation and diagnosis of obstructive sleep apnea (OSA). The evidence is limited to small case series studies that do not allow full evaluation of this technology. Based on the peer review medical literature the evidence is insufficient to determine the effect on net health outcomes.

 

 

Practice Guidelines and Position Statements

American Academy of Sleep Medicine (AASM)

In 2017, the American Academy of Sleep Medicine (AASM) issued clinical practice guideline for diagnostic testing for adult obstructive sleep apnea which includes the following recommendations:

  • We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG)
  • We recommend that polysomnography, or home sleep apnea testing with technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG)
  • We recommend that if a single home apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG)
  • We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG)
  • We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK)
  • We suggest that when the initial polysomnography is negative and clinical suspicion for OSA remains, a second polysomnography be considered for the diagnosis of OSA. (WEAK)   


In 2005, the American Academy of Sleep Medicine (AASM) issued practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test, which included the following recommendations:

  • Multiple sleep latency testing (MSLT) is indicated as part of the evaluation of patients with suspected narcolepsy to confirm diagnosis and may be useful in the evaluation of patients with suspected idiopathic hypersomnia.
  • Multiple sleep latency testing (MSLT) is not routinely indicated in the initial evaluation and diagnosis of obstructive sleep apnea syndrome or in the assessment of change following treating with nasal continuous positive airway pressure (CPAP).
  • Multiple sleep latency testing (MSLT) is not routinely indicated for evaluation of sleepiness in medical and neurological disorders (other than narcolepsy), insomnia, or circadian rhythm disorders.

 

Prior Approval:

 

Not applicable

 

Policy:

  • This medical policy applies to patients 18 years and older
  • See Related Medical Policy 02.01.55: Sleep Studies in Children and Adoloscents 
  • For guidance regarding Positive Airway Pressure (PAP) Devices see Wellmark Provider Guide - HME, Orthotics and Prostheses

 

Home Sleep Study (Unsupervised/Unattended) (95800, 95801, 95806, G0398, G0399, G0400)

Note: Interpretation of test results of a home sleep study test (unattended/unattended) should be validated by a board certified sleep specialist.

Home Sleep Study Testing (Unsupervised/Unattended)

Home sleep study testing (unsupervised/unattended) may be considered medically necessary in adult patients who have symptoms suggestive of  moderate to severe obstructive sleep apnea (OSA), when ALL of the following criteria are met:
Patients considered to have a symptom suggestive of  moderate to severe OSA must have at least two of the following:

  • *Habitual snoring or gasping/choking episodes associated with awakenings;
  • *Observed apneas;
  • Excessive daytime sleepiness as evidenced by one of the following:
    • Questionnaires (e.g. Epworth Sleepiness Scale >10, Berlin, STOP or STOP BANG)
    • Inappropriate day time napping (e.g. during driving, conversation or eating)
    • sleepiness that interferes with daily activities not explained by other conditions; 
  • A body mass index ≥ 30 kg/m2
  • Increased neck circumference >17 inches for men or >16 inches in women;
  • Morning headaches;
  • Sleep fragmentation or frequent unexplained arousals from sleep;
  • Decreased concentration/memory loss;
  • Treatment resistant hypertension/unexplained hypertension

*If no bed partner is available to report snoring or observed apneas, the patient must still meet the criteria as it relates to other signs and symptoms suggestive of OSA;
AND
Have absence of health conditions that might alter ventilation or decrease the accuracy of the home study including, but not limited to the following:

  • Moderate to severe lung  (pulmonary) disease
  • Congestive Heart Failure
  • Hypoventilation syndrome (as evidence by a serum bicarbonate >27 mEq/L or PaCO2 >45mmHG)
  • Neuromuscular disease (e.g. related respiratory weakness due to neuromuscular condition - Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis)
  • History of stroke
  • Chronic opiate medication use

AND
Must not be suspected of having other sleep disorders including but not limited to the following: 

  • Central sleep apnea
  • Sleep related movement disorders (periodic limb movement disorder/restless leg syndrome)
  • Severe insomnia
  • Parasomnias
  • Narcolepsy

AND
Any one of the following sleep monitoring devices:

  • sleep monitoring using a Type II device; or
  • sleep monitoring using a Type III device; or
  • sleep monitoring using a Type IV(A) device, which must measure a minimum of three channels and must provide measurement of apnea-hypopnea index (AHI)

Notes:

  • See Description information above for a full description of sleep monitoring devices.
  • Respiratory disturbance index (RDI) may be used in place of apnea/hypopnea index (AHI) in home sleep studies (unsupervised/unattended)
  • Home sleep study testing (unsupervised/unattended) may be performed over multiple nights with a single interpretation and is considered a single sleep study for purposes of reimbursement.
Repeat Home Sleep Study Testing (Unsupervised/Unattended)

Repeat home sleep study testing (unsupervised/unattended) may be considered medically necessary in adult patients for any of the following:

  • To assess efficacy of surgery or oral appliance/device; OR
  • A non-diagnostic home sleep study within the past 3 months (e.g. technical complications or negative test results) when the patient has a high pretest probability of OSA and continued symptoms suggestive of OSA; OR
  • Failure to resolve OSA symptoms or recurrence of symptoms during treatment; OR
  • To re-evaluate the diagnosis of OSA and need for continued PAP therapy when health status changes occur (e.g. if there is a significant change in weight or change in symptoms suggesting that PAP therapy should be adjusted or possibly discontinued).
Home sleep study (unsupervised/unattended) for  asymptomatic individuals

Home sleep study testing (unattended/unsupervised) for an asymptomatic individual is considered not medically necessary

PAP Device Titration with Pressure Titration Home Based

Home/unattended PAP device pressure titration may be considered medically necessary for adult patients who meet criteria for home sleep study testing above and who have a diagnosis of OSA.

  • Home based pap device titration using auto-adjusting positive airway pressure (APAP) may be considered medically necessary for titration of pressure in adult patients with diagnosis of OSA.

Note: When a diagnosis of OSA is established following home sleep study testing, home titration to determine a fixed PAP pressure can be effectively completed using auto-titrating positive airway pressure (APAP). Evidence from several well-designed trials demonstrates that home PAP titration using APAP compared to in-facility/laboratory titration results in similar outcomes in terms of improvement in AHI, Epworth Sleepiness scores, and PAP

 

Supervised Facility or Sleep Laboratory Sleep Study (Polysomnography) (95807, 95808, 95810, 95811)

Note: Interpretation of test results of a supervised facility/sleep laboratory sleep study should be validated by a board certified sleep specialist.

Supervised sleep study performed in a facility or sleep laboratory for an adult patient who meets criteria for a home sleep study   A supervised sleep study performed in a facility or sleep laboratory is considered not medically necessary when an adult patient meets the criteria above for a home sleep study
Initial - supervised sleep study performed in a facility or sleep laboratory 

May be considered medically necessary in adult patients with symptoms suggestive of moderate to severe obstructive sleep apnea (OSA) when one of the following are met:   

  • A previous home sleep study was technically inadequate; OR
  • A previous home sleep study failed to establish the diagnosis of OSA in a patient with high pretest probability of OSA; OR
  • A home sleep study is contraindicated due to other health conditions that might alter ventilation or decrease the accuracy of the study, including but not limited to the following:
    • Moderate to severe lung  (pulmonary) disease
    • Congestive Heart Failure
    • Hypoventilation syndrome (as evidence by a serum bicarbonate >27 mEq/L or PaCO2 >45mmHG)
    • Neuromuscular disease (e.g. related respiratory weakness due to neuromuscular condition - Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis)
    • History of stroke
    • Chronic opiate medication use; OR
  • When testing is done to rule out other sleep related disorders such as central sleep apnea; sleep related movement disorders (periodic limb movement disorder/restless leg syndrome); severe insomnia; parasomnias; narcolepsy.

Note: Patients considered to have symptoms suggestive of moderate to severe OSA will include the following:

  • Habitual snoring or gasping/choking episodes associated with awakenings
  • Observed apneas
  • Excessive daytime sleepiness as evidenced by questionnaire (e.g. Epworth Sleepiness Scale; Berlin; STOP or STOP-BANG)
  • Inappropriate day time napping (e.g. during driving, conversation or eating)
  • Sleepiness that interferes with daily activities not explained by other conditions
  • A BMI >30 kg/m2
  • Increased neck circumference >17 inches for men or > 16 inches for women
  • Morning headaches
  • Sleep fragmentation or frequent unexplained arousals from sleep
  • Decreased concentration/memory loss
  • Treatment resistant hypertention/unexplained hypertension
Split night sleep study performed in a facility or sleep laboratory

A split-night sleep study performed in a  facility or sleep laboratory (initial diagnostic sleep study followed by PAP titration during sleep study on the same night) is an alternative to one full night  diagnostic sleep study followed by a second night of titration and may be considered medically necessary when  the following criteria are met:

  • Meets the criteria above for initial supervised sleep study performed in a facility or sleep laboratory; AND
  • An AHI of at least 40/hour is documented during a minimum of 2 hours of diagnostic sleep study. Split-night studies may sometimes be considered at an AHI of 20 to 40, based on clinical judgement (e.g. there are repetitive long obstructions or major desaturations).  
    • AHI values below 40, determination of PAP pressure requirements based on split-night studies, may be less accurate than in full-night calibrations); AND
  • PAP titration is carried out for more than 3 hours (because respiratory events can worsen as the night progresses). 
Repeat supervised sleep study performed in a facility or sleep laboratory

Repeat supervised sleep study performed in a facility or sleep laboratory may be considered medically necessary in adult patients for one of the following reasons:

  • To assess efficacy of surgery or an oral appliance/device; OR
  • A non-diagnostic home sleep study occurred within the past 3 months (negative/inconclusive test results) when the patient has a  high pretest probability of OSA, and continued symptoms suggestive of OSA; OR
  • Failure of resolution of symptoms or recurrence of symptoms during treatment; OR
  • To re-evaluate the diagnosis of OSA and need for continued PAP therapy (e.g. if there is a significant change in weight or change in symptoms suggesting that PAP therapy should be adjusted or possibly discontinued), in a member who has contraindication to home based testing.
Supervised sleep study performed in a facility or sleep laboratory for  asymptomatic individuals

Supervised sleep study performed in a facility or sleep laboratory for an asymptomatic individual is considered not medically necessary

PAP Device Titration with Pressure Titration – Facility Based
  • Facility or sleep laboratory attended PAP device pressure titration is considered not medically necessary when adult patients meet the criteria for unattended/home based sleep study testing and home based PAP device titration as indicated above.
  • Facility or sleep laboratory attended PAP device pressure titration may be considered medically necessary for patients when home/unattended PAP device pressure titration is contraindicated due to other health conditions that might alter ventilation or decrease accuracy.
    • Contraindications to home/unattended PAP device pressure titration include but are not limited to the following health conditions:
      • Moderate to severe lung (pulmonary disease)
      • Congestive heart failure
      • Hypoventilation syndrome (as evidence by a serum bicarbonate >27 mEq/L or PaCO2 > 45 mmHG)
      • Neuromuscular disease (e.g. related respiratory weakness due to neuromuscular condition - Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis)
      • History of stroke
      • Chronic opiate medication use; OR
    • When testing is done to rule out other sleep disorders such as central sleep apnea; sleep related movement disorders (periodic limb movement disorder/restless leg syndrome); severe insomnia; parasomnias; narcolepsy.

 

Supervised sleep study performed in a facility or sleep laboratory (95807, 95808, 95810, 95811) or a home sleep study (unsupervised/unattended) (95800, 95801, 95806, G0398, G0399, G0400), are considered not medically necessary including but not limited to the following indications:

  • The diagnosis of chronic lung disease
  • The diagnosis of circadian rhythm sleep disorders
  • Transient insomnia
  • Insomnia associated to psychiatric or neuropsychiatric disorders
  • The diagnosis of bruxism (grinding of teeth)
  • Facility or sleep laboratory attended PAP
  • Establishment of a diagnosis or treatment of depression
  • Migraine headaches/headaches

 

Multiple Sleep Latency Test (MSLT) (95805)
Initial multiple sleep latency testing (MSLT)

Multiple sleep latency test (MSLT) would be considered medically necessary for the following indications:

  • For evaluation of symptoms of narcolepsy to confirm the diagnosis; OR
  • For evaluation of persons with suspected idiopathic hypersomnia to help differentiate idiopathic hypersomnia from narcolepsy; OR
  • Individuals with previously identified sleep disorder such as obstructive sleep apnea syndrome or other sleep related breathing disorder who continue to experience excessive sleepiness despite optimal treatment may require evaluation for possible narcolepsy. 

Multiple sleep latency test (MSLT) is considered not medically necessary for any one of the following:

  • When performed in the initial evaluation and diagnosis of obstructive sleep apnea syndrome.
  • For routine follow up after treatment of sleep related disorders
  • For evaluation of sleepiness in medical and neurological disorders (other than narcolepsy and idiopathic hypersomnia), insomnia or circadian rhythm disorders
  • When performed in the home (unattended/unsupervised) as it has not been proven to be equivalent to a formal multiple sleep latency test (MSLT) performed in a sleep laboratory or facility.  
Repeat multiple sleep latency testing (MSLT)

Repeat multiple sleep latency test (MSLT) would be considered not medically necessary, unless one of the following occurs:

  • The initial test was invalid or uninterpretable; OR
  • Did not provide polygraphic confirmation after a properly performed test and the clinical history strongly indicates a diagnosis of narcolepsy or idiopathic hypersomnia; OR
  • When the response to treatment needs to be ascertained.

 

Additional Diagnostic Tests for Obstructive Sleep Apnea (OSA)

 

 

Actigraphy

Actigraphy is considered investigational for the routine diagnosis, assessment of severity or management of any sleep disorders.

 

Overall, progress has been made since 2007 American Academy of Sleep Medicine (AASM) research recommendations in assessing the validity of different algorithms in comparison with the reference standard. Although actigraphy appears to provide reliable measures of sleep onset and wake time in some patient populations, the clinical utility of actigraphy over the less expensive sleep diary has not been demonstrated. Moreover, evidence indicates that actigraphy does not provide a reliable measure of sleep efficiency in clinical populations. Evidence to date does not indicate that this technology is as beneficial as the established alternatives or that the use of actigraphy would result in improved health outcomes for patients with sleep disorders. Therefore, actigraphy is considered investigational.

 

Topographic EEG

Based on peer reviewed literature topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA.  However, the evidence is limited to small case series studies that do not allow full evaluation of this technology.  At this time, the level of evidence supporting topographic brain mapping is insufficient and therefore is considered investigational

 

SleepStrip

SleepStrip has a low correlation with the AHI as measured by PSG, and further studies are needed before this device can be recommended as a screening tool for the diagnosis of OSA. Therefore, the clinical effectiveness of this diagnostic testing has not been established and is considered investigational.

 

Pap-Nap Study

There is insufficient evidence in the published medical literature to determine whether PAP-nap studies result in improved adherence to therapy or improved patient outcomes. Therefore, the clinical effectiveness of this diagnostic testing has not been established and is considered investigational

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • 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)
  • 95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)
  • 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
  • 95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement)
  • 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
  • 95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
  • 95810 Age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  • 95811 Age 6 years or older, 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 
  • 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
  • S8040 Topographic brain mapping

 

Selected References:

  • The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
  • 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.
  • 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.
  • 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.
  • ECRI. Actigraphy for the Evaluation of Sleep Disorders. Plymouth Meeting (PA): ECRI 2005 March 9. 9 p.  (ECRI Hotline Response).
  • 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.
  • 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 3/26/2013.
  • 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. Accessed 3/26/2013.
  • Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, SchwabRJ, Weaver EM, Weinsteing MD; Adult Obstructive Sleep Apnea Task Force of 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].
  • 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].
  • 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]. 
  • 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.
  • Agency for Healthcare Research and Quality (AHRQ).  Effective Health Care Program: Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review Number 32.
  • ECRI. Oral Appliances for Treating Obstructive Sleep Apnea and Upper Airway Resistance Syndrome. Plymouth Meeting (PA): ECRI Institute; 2011 November 14. [Hotline Service].
  • ECRI. Ambulatory/Portable Sleep Apnea Monitors for Diagnosis of Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI Institute; 2011 June 22. [Hotline Service].
  • ECRI. Autotitrating versus Fixed Continuous Positive Airway Pressure for Treating Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI Institute; 2011 November 1. [Hotline Service].
  • ECRI. Actigraphy for the Evaluation of Sleep Disorders. Plymouth Meeting (PA): ECRI Institute; 2011 July 18. [Hotline Service].
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  • Centers for Medicare & Medicaid Services, National Coverage Determination (NCD) for Sleep Testing for Obstructive Sleep Apnea (OSA) (240.4.1).
  • Nancy A. Collop M.D. et al. Obstructive Sleep Apnea Devices for Out of Center (OOC) Testing: Technology Evalauation. Journal of Clinical Sleep Medicine, Vol.7, No. 5, 2011
  • American Academy of Sleep Medicine (AASM) Clarifies Hypopnea Scoring Criteria, September 23, 2013. AASM News Archives.
  • American Academy of Sleep Medicine (AASM) Practice Parameters for Clinical Use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. Sleep, Vol. 28, No.1.2005.
  • American Academy of Sleep Medicine(AASM) Practice Parameters for the Use of Actigraphy in the Assessment of Sleep and Sleep Disorders: An Update for 2007. Sleep Vol. 30, No. 4, 2007.
  • Lawrence J. Epstein, M.D. et al., Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine,  Clinical Guidelines for the Evaluation, Management and Long Term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine, Vol. 5, No.3, 2009.
  • Nancy A. Collop, M.D., et. al. Portable Monitoring Task Force of the American Academy of Sleep Medicine, Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Apnea in Adult Patients, Journal of Clinical Sleep Medicine, Vol. 3, No. 7, 2007.
  • UpToDate. Clinical Presentation and Diagnosis of Obstructive Sleep Apnea in Adults. Lewis R. Kline, M.D.. Topic last updated February 9, 2017.
  • UpToDate. Sleep Related Breathing Disorders in Adults. Definitions. Kingman P. Strohl M.D., Topic last updated January 29, 2013.
  • UpToDate. Portable Monitoring in Obstructive Sleep Apnea in Adults. Nancy Collop, M.D., Topic last updated February 19, 2014.
  • UpToDate. Polysomnography in Obstructive Sleep Apnea in Adults. Richard P. Milliman, M.D., Naomi R. Kramer, M.D., Topic last updated September 20, 2013.
  • Richard J. Schwab, et al. An American Thoracic Society Statement: Continuous Positive Airway Pressure Adherence Tracking Systems. The Optimal Monitoring Strategies and Outcome Measures in Adults.  Am J Respir Crit Care Med, Vol 188, Iss. 5, pp 613-620, Sep 1, 2013
  • Clete A. Kushida, M.D., PhD, RPSGT (Chair). et al, Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea, Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, Vol 4, No. 2, 2008.
  • Clete A. Kushida, M.D., PhD, RPSGT, et al., Practice Parameters for the Use of Continuous and Bilevel Positive Airway Pressure Devices to Treat Adult Patients with Sleep Related Breathing Disorders, An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No. 3, 2006.
  • Timothy Morgenthaler, M.D., et al., Practice Parameters for the Use of Autotitrating Continuous Positive Airway Pressure Devices for Titrating Pressures and Treating Adult Patients with Obstructive Sleep Apnea Syndrome: An Update for 2007, An American Academy of Sleep Medicine Report. Sleep, Vol. 31, No.1, 2008
  • UpToDate Initiation of Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Adults. Nilesh B. Dave, M.D., MPH, Lee K. Brown, M.D.. Topic last updated July 2, 2013
  • UpToDate Adherence with Continuous Positive Airway Pressure (CPAP). Terri Weaver, PhD, R.N., FAAN, Nancy Collop, M.D., Topic last updated November 25, 2013
  • Clete A. Kushida M.D., PhD, et. al. Practice Parameters for the Polysomnography and Related Procedures: An Update for 2005, The American Academy of Sleep Medicine, Sleep, Vol. 28, No. 4, 2005.
  • ECRI. Hotline Response. Continuous Positive Airway Pressure for Treating Obstructive Sleep Apnea July 2014.
  • ECRI. Hotline Response. Ambulatory Sleep Apnea Monitors for Diagnosing Obstructive Sleep Apnea. June 2014.
  • Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. Oct 15 2012;8(5):597-619. PMID 23066376
  • Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-100551) AHRQ Publication No. 11-EHC052-EF. Rockville MD: Agency for Healthcare Research and Quality Jul 2011.
  • Mutter TC, Chateau D, Moffatt M, et al. A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications? Anesthesiology. Oct 2014;121(4):707-718. PMID 25247853
  • Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep. Jun 2012;35(6):757-767. PMID 22654195
  • 9. Kuna ST, Gurubhagavatula I, Maislin G, et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med. May 1 2011;183(9):1238-1244. PMID 21471093
  • Skomro RP, Gjevre J, Reid J, et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest. Aug 2010;138(2):257-263. PMID 20173052
  • Andreu AL, Chiner E, Sancho-Chust JN, et al. Effect of an ambulatory diagnostic and treatment programme in patients with sleep apnoea. Eur Respir J. Feb 2012;39(2):305-312. PMID 21719490
  • Bruyneel M, Ninane V. Unattended home-based polysomnography for sleep disordered breathing: current concepts and perspectives. Sleep Med Rev. Aug 2014;18(4):341-347. PMID 24388970
  • Chai-Coetzer CL, Antic NA, Rowland LS, et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial. JAMA. Mar 13 2013;309(10):997-1004. PMID 23483174
  • Berry RB, Hill G, Thompson L, et al. Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. Sleep. Oct 1 2008;31(10):1423-1431. PMID 18853940
  • Pang KP, Gourin CG, Terris DJ. A comparison of polysomnography and the WatchPAT in the diagnosis of obstructive sleep apnea. Otolaryngol Head Neck Surg. Oct 2007;137(4):665-668. PMID 17903588
  • Penzel T, Kesper K, Pinnow I, et al. Peripheral arterial tonometry, oximetry and actigraphy for ambulatory recording of sleep apnea. Physiol Meas. Aug 2004;25(4):1025-1036. PMID 15382839
  • Pittman SD, Ayas NT, MacDonald MM, et al. Using a wrist-worn device based on peripheral arterial tonometry to diagnose obstructive sleep apnea: in-laboratory and ambulatory validation. Sleep. Aug 1 2004;27(5):923-933. PMID 15453551
  • Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. Dec 15 2007;3(7):737-747. PMID 18198809
  • Ayappa I, Norman RG, Seelall V, et al. Validation of a self-applied unattended monitor for sleep disordered breathing. J Clin Sleep Med. Feb 15 2008;4(1):26-37. PMID 18350959
  • Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. Apr 2012;35(4):477-481. PMID 22467985
  • Berry RB, Parish JM, Hartse KM. The use of auto-titrating continuous positive airway pressure for treatment of adult obstructive sleep apnea. An American Academy of Sleep Medicine review. Sleep. Mar 15 2002;25(2):148-173. PMID 11902425
  • Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. Jan 1 2008;31(1):141-147. PMID 18220088
  • Berry RB, Kryger MH, Massie CA. A novel nasal expiratory positive airway pressure (EPAP) device for the treatment of obstructive sleep apnea: a randomized controlled trial. Sleep. Apr 2011;34(4):479-485. PMID 21461326
  • Kryger MH, Berry RB, Massie CA. Long-term use of a nasal expiratory positive airway pressure (EPAP) device as a treatment for obstructive sleep apnea (OSA). J Clin Sleep Med. Oct 15 2011;7(5):449-453B. PMID 22003339
  • Qaseem A, Dallas P, Owens DK, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Aug 2014; 161(3):210-20.
  • Qaseem A, Holty JE, Owens DK, et al. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Gideline From the American College of Physicians. Ann Intern Med Sept 2013; 159(7):471-83.
  • American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. Peri-operative Management of Obstructive Sleep Apnea. Surg Obes Relat Dis. 2012 May-Jun;8(3):e27-32.
  • National Institute for Health and Clinical Excellence. NICE technology appraisal guidance 139. Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome. 2010.
  • Berry R, Sriram P. Auto Adjusting Positive Airway Pressure Treatment for Sleep Apnea Diagnosed by Home Sleep Testing. Journal of Clinical Sleep Medicine Vol. 10,No. 12. 2014 
  • Marino M, Li Y, Rueschman MN, et al. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Sleep. Nov 2013;36(11):1747-1755. PMID 24179309
  • Kaplan KA, Talbot LS, Gruber J, et al. Evaluating sleep in bipolar disorder: comparison between actigraphy, polysomnography, and sleep diary. Bipolar Disord. Dec 2012;14(8):870-879. PMID 23167935
  • Taibi DM, Landis CA, Vitiello MV. Concordance of polysomnographic and actigraphic measurement of sleep and wake in older women with insomnia. J Clin Sleep Med. Mar 15 2013;9(3):217-225. PMID 23493815
  • Louter M, Arends JB, Bloem BR, et al. Actigraphy as a diagnostic aid for REM sleep behavior disorder in Parkinson's disease. BMC Neurol. 2014;14:76. PMID 24708629
  • Blackwell T, Ancoli-Israel S, Redline S, et al. Factors that may influence the classification of sleep-wake by wrist actigraphy: the MrOS Sleep Study. J Clin Sleep Med. Aug 15 2011;7(4):357-367. PMID 21897772
  • Plante DT. Leg actigraphy to quantify periodic limb movements of sleep: a systematic review and meta-analysis. Sleep Med Rev. Oct 2014;18(5):425-434. PMID 24726711
  • Kapur V, Auckley D, Chowdhuri S, et. al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: an American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine Vol. 13 No. 3, 2017.
  • U.S. Preventative Services Task Force (USPSTF). U.S. Preventative Services Task Force Issues Recommendation Statement on Screening for Obstructive Sleep Apnea in Adults. January 24, 2017.
  • UpToDate. Overview of Obstructive Sleep Apnea in Adults. Kingman P. Strohl M.D., Topic last updated June 24, 2016.
  • UpToDate. Insufficient Sleep: Evalation and Management. Kiran Maski M.D., Topic last updated July 28, 2016.
  • UpToDate. Clinical Manifestations and Diagnosis of Obesity Hypoventilation Syndrome. Amanda Piper PhD, Brendon Yee MBChB, PhD. Topic last updated February 2, 2017.
  • Dinc AE, Yilmaz M, Tutar H, et. al. Reliability of SleepStrip as a screening test in obstructive sleep apnea patients. Eur Arch Otorhinolaryngol 2014 Oct:271(10):2813-8
  • Levenson JC, Troxel WM, Begley A, et. al. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. J Clin Sleep Med 2013 Feb 1:9(2):125-31
  • Krakow B, Ulibarri V, Melendrez D, et. al. A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP). J Clin Sleep Med 2008 Jun 15;4(3):212-22
  • American Sleep Association PAP-NAP.
  • American Academy of Sleep Medicine Coding FAQ.

 

Policy History:

  • June 2017 - Interim Review, Policy Revised
  • March 2017 - Annual Review, Policy Revised
  • March 2016 - Annual Review, Policy Revised
  • October 2015 - Interim Review, Policy Revised
  • March 2015 - Annual Review, Policy Revised
  • October 2014 - New Policy Created For Children, Policy Revised
  • July 2014 - Interim Review, Policy Revised
  • June 2014 - Interim Review, Policy Revised
  • April 2014 - Annual Review, Policy Revised
  • May 2013 - Annual Review, Policy Revised
  • May 2012 - Annual Review, Policy Renewed
  • July 2011 - Annual Review, Policy Revised

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.

 

*CPT® is a registered trademark of the American Medical Association.