Medical Policy: 07.01.21 
Original Effective Date: January 2001 
Reviewed: March 2016 
Revised: March 2016 


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. OSA is typically diagnosed by overnight monitoring with polysomnography (PSG).

 

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, Wisconsin, STOP and STOP-BANG).  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 a method developed for non-sleep specialists to access the signs and symptoms of OSA (Snore, Tired, Observed Apnea, Blood Pressure, BMI, Age, Neck and Gender) and has been shown to have 97% sensitivity and negative predictive value of 96% (specificity of 33%) for the identification of patients with severe OSA (AHI >30).

 

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/sleep laboratory or in the home.

 

Supervised Facility or Laboratory Polysomnography (Sleep Study)

A facility based polysomnography (PSG) is conducted in an accredited facility or sleep laboratory site. Facility/laboratory sleep study tests are supervised by a trained sleep technician.  Sleep studies performed in a facility/ sleep laboratory 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/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 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 elctro-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.  

 

Full-night or split-night facility-based PSG may be indicated for those with suspected OSA who have significant medical comorbidities that could degrade the accuracy of home/portable testing, or are suspected to have sleep disorders other than OSA. Facility-based PSG may also be indicated when portable monitoring is technically inadequate or fails to establish the diagnosis in an individual with a high pretest probability of OSA, or when the individual and caregiver/companion is incapable of operating home testing equipment.

 

Unsupervised Home Sleep Test (HST)/Home Sleep Studies 

Home based sleep testing and PAP titration is an alternative to facility based sleep disorder testing that is supported by the American Academy of Sleep Medicine for diagnosing certain individuals who are suspected of having obstructive sleep apnea (OSA) or for treating individuals who have OSA and require follow-up-testing.

 

Performance of home based sleep testing is limited to FDA approved devices furnished with adequate patient instruction that is documented in the medical record and support to ensure successful completion and reliable results. 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. . Home sleep testing allows for a more cost effective setting, which is often more comfortable and convenient for the individual and meets their medical needs. 

 

Based on clinical guidelines on the use of unattended home sleep studies/home sleep testing 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 unattended sleep studies are not appropriate for the diagnosis of OSA in patients with significant co-morbid medical conditions that may degrade the accuracy of unattended sleep studies, including moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure. The guidelines also note that unattended studies are not appropriate for the diagnostic evaluation of OSA in patients suspected of having other sleep disorders (central sleep apnea, parasomnias, narcolepsy of perodic limb movement disorder). Also, unattended sleep studies are not appropriate for general screening of asymptomatic populations.

 

Home sleep testing is a sleep study performed in the home that utilizes portable monitoring (PM) devices that are designed to be used by an individual without supervision of a sleep technologist. The system usually consists of a recording and related accessories. PM devices measure fewer parameters than a laboratory based sleep study. The American Academy of Sleep Medicine has added guidelines for the categorization of home sleep testing devices based on measurements of Sleep, Cardiovascular, Oximetry, Position, Effort and Respiratory (SCOPER) parameters.  These guidelines are being utilized along with the more commonly referred to (Type 1-IV) sleep monitoring or classification systems below.

 

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 CPAP 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/hr is documented during 2 hours of a diagnostic study but may be considered for an AHI of 20-40/hr based on clinical judgement.    

 

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/hr or greater than 5/hr 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/hr is considered severe OSA  

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.

 

Specialist Training
The medical professional who is interpreting a supervised polysomnography or unattended 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, e.g, review of symptoms and device utilization between 30 and 90 days.

 

Medical Management
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 [BPAP], or auto-adjusting CPAP [APAP]). 

Multiple Sleep Latency Testing (MSLT)
The multiple sleep latency test (MLST) 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 narcoplepsy. 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), insomnia, or circadian rhythm disorders.

 

Additional Tests and Treatment for OSA

Actigraphy      
Actigraphy refers to the assessment of activity patterns by devices typically placed on the wrist or ankle that record body movement, which is interpreted by computer algorithms as periods of sleep (absence of activity) and wake (activity). Sleep/wake cycles may be altered in sleep disorders including insomnia and circadian rhythm sleep disorders.

 

Actigraphic 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 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.

 

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. Also, recommends actigraphy as an “option”to characterize circadian rhythm patterns or sleep disturbances in individuals with insomnia, including insomnia associated depression.

 

The clinical validity of actigraphy, the assessment of activity patterns by devices typically placed on the write or ankle that record body movement, depends, to a large extent, on the modality with which it is being compared.

  • Comparisons with sleep diaries show reasonable correlations for measures fo bedtime, sleep onset, and wake time in adults but not in adolescents. 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 indicates that, with the appropriate sensitivity threshold, actigraphy has sufficient sensitivity to detect sleep but has poor specificity in distinguishing between wake and sleep. The literature also indicates  that the accuracy of actigraphy to differentiate between wake and sleep decreases s the level of sleep disturbance increases.

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. Therefore, actigraphy is considered investigational.

 

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.

 

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 or improved patient outcomes.


Oral Pressure Therapy
Oral pressure therapy (OPT)/the Winx therapy system is a light, oral vacuum delivered by a quiet console through a slim tube connected to a soft, flexible mouth-piece.  The mouthpiece and vacuum work together to gently pull the soft palate forward and stabilize the tongue, increasing the size of the airway and allowing for natural breathing to occur during sleep. No full length, peer reviewed studies on oral pressure therapy have been identified in the published literature. Therefore, it is not possible to evaluate the efficacy of this treatment based on scientific evidence and therefore is considered investigational.


Prior Approval:

 

Not applicable


Policy:

This medical policy applies to patients 18 years and older

See Related Policy: Sleep Studies in Children and Adoloscents  02.01.55 

For guidance regarding Positive Airway Pressure (PAP) Devices see Wellmark Provider Guide - HME, Orthotics and Prostheses

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

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

Initial testing

Unsupervised (unattended) home sleep studies/home sleep test may be considered medically necessary in adult patients who are at high pre-test probability for moderate to severe obstructive sleep apnea (OSA), when ALL of the following criteria are met:

Patients considered high pre-test probability for 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 (Epworth Sleepiness Scale >10, Berlin, Wisconsin, STOP or STOP BANG)
    • Inappropriate day time napping (e.g. during driving, conversation or eating), or
    • 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

In addition, those patients eligible for an unattended home sleep study must have no evidence of a co-morbid medical condition including but not limited to any of the following as they might alter ventilation or require alternative treatment;

  • Moderate to Severe Pulmonary Disease
  • Congestive Heart Failure
  • Obesity hypoventilation syndrome
  • Neuromuscular disease (Parkinson’s, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis)

AND

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

 

  • Central sleep apnea
  • Periodic limb movement disorder
  • Restless leg syndrome
  • 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 unattended sleep studies

 

Unsupervised (unattended) home sleep studies/home sleep tests are considered not medically necessary in adult patients who do not meet the criteria above as they would be considered low risk for OSA. Evidence to date shows that home sleep tests/studies have been predominately performed in high risk populations for moderate to severe obstructive sleep apnea (OSA) and should be limited to this group.  

Sleep studies using devices that do not provide a measurement of apnea-hypopnea index (AHI) and oxygen saturation are considered not medically necessary because they do not provide sufficient information to prescribe treatment. 

Notes

  • Unsupervised (unattended) home sleep study/home sleep test is typically performed over multiple nights with a single interpretation and is considered a single sleep study for purposes of reimbursement.
  • When a diagnosis of OSA is established following a home sleep study/home sleep test (portable study), home titration to determine a fixed CPAP pressure can be effectively completed using auto-titrating positive airway pressure. 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.

Repeat Testing

Repeat Testing Unsupervised Home Sleep Study/Home Sleep Test (95800, 95801, 95806, G0398, G0399, G0400)

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

  • To assess efficacy of surgery or oral appliances/devices.
  • A non-diagnostic home study within the past 3 months (e.g. technical complications or negative test with a high pretest probability of OSA).
  • Failure of resolution of symptoms or recurrence of symptoms during treatment.
  • 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).

Unsupervised (unattended) home sleep studies/home sleep testing that do not meet the above criteria for repeat studies are considered not medically necessary.

Note: Unsupervised (unattended) home sleep study/home sleep test is typically performed over multiple nights with a single interpretation and is considered a single sleep study for purposes of reimbursement.

 

Supervised Facility or Sleep Laboratory Polysomnography Sleep Study (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.

 

Initial Testing

 

Supervised polysomnography (PSG) (sleep study) performed in a facility or sleep laboratory may be considered medically necessary in adult patients with a moderate or high pretest probability of OSA in the following situations:

  • When patients do not meet criteria for unattended home sleep study/home sleep test as described above (contraindicated due to co-morbid health conditions which decrease the accuracy of the study, including but not limited to moderate severe pulmonary disease, neuromuscular disease, congestive heart failure or hypoventilation syndrome); OR
  • A previous home study was technically inadequate; OR
  • A previous home study failed to establish the diagnosis of OSA in a patient with high pretest probability of OSA; OR
  • Testing is being done for patients to rule out other sleep disorders such as central sleep apnea, injurious or potentially injurious parasomnias, narcolepsy or periodic limb movement disorder (PLMD).

Supervised polysomnography (PSG) (sleep study) performed in a facility or sleep laboratory is considered not medically necessary when the above criteria is not met.

Supervised polysomnography (PSG) (sleep study) performed in a facility or sleep laboratory is considered not medically necessary when adult patients meet criteria for unsupervised (unattended) home sleep studies/home sleep tests.

Supervised polysomnography (PSG) (sleep study) performed in a facility or sleep laboratory for an asymptomatic individual is considered not medically necessary.

 

Split-Night Studies

A split-night facility/laboratory sleep study (initial diagnostic sleep study followed by PAP titration during sleep study on the same night) as an alternative to one full night of diagnostic sleep study followed by a second night of titration may be considered medically necessary in adult patients if the following 4 criteria are met:

  • An AHI of at least 40 is documented during a minimum of 2 hours diagnostic PSG. Split-night studies may sometimes be considered at an AHI of 20 to 40, based on clinical judgement (e.g. if below 40, determination of PAP level requirements, based on split-night studies, may be less accurate than in full-night calibrations).
  • PAP titration is carried out for more than 3 hours (because respiratory events can worsen as they night progresses).
  • Sleep study (PSG) documents that PAP eliminates or nearly eliminates the respiratory events during rapid eye movement (REM) and non-REM (NREM) sleep, including REP sleep with the patient in the supine position.
  • A second full night or PSG or PAP titration is performed in the diagnosis of a sleep related breathing disorder is confirmed, but criteria b and c are not met.    

 

Repeat Testing

 

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

 

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

  • To initiate and titrate PAP in adult patients who have:
    • An AHI at least 15 per hour; OR
    • An AHI of at least 5 per hour in a patient with excessive day time sleepiness or unexplained hypertension.

Note: A split-night study, in which moderate to severe OSA is documented during the first portion of the study using PSG, followed by PAP during the second portion of the study, can eliminate the need for a second study to titrate PAP (see split-night study criteria above)

  • To assess efficacy of surgery or oral appliances/devices.
  • A non-diagnostic home study within the past 3 months (e.g. technical complications or negative test with a high pretest probability of OSA).
  • Failure of resolution of symptoms or recurrence of symptoms during treatment.
  • 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).

Supervised polysomnography (PSG) (sleep study) performed in a facility or sleep laboratory sleep that do not meet the above criteria for repeat studies are considered not medically necessary.

 

Supervised polysomnography (PSG) in a facility/sleep laboratory or unsupervised (unattended) home sleep studies 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)
  • Establishment of a diagnosis or treatment of depression
  • Migraine headaches/headaches

Based on peer reviewed literature supervised polysomnography (PSG) or (unattended) home sleep test/studies are not indicated in the routine evaluation for the above listed indications (list is not all inclusive) nor has this testing shown to improve patient health outcomes and therefore, is considered not medically necessary.

 

Nocturnal Pulse Oximetry

Guidelines indicate that nocturnal pulse oximetry alone is not an appropriate diagnostic tool for diagnosing obstructive sleep apnea (OSA). Pulse oximetry when used alone, has not shown to have an adequate predictive value to rule out OSA and therefore, is considered not medically necessary. Also, all patients with symptoms suggestive of OSA would require polysomnography regardless of whether the pulse oximetry was positive or negative.

 

Multiple Sleep Latency Test (MSLT) (95805)

 

Initial Testing

 

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

Overnight polysomnography is the diagnostic procedure of choice for evaluation of individuals with possible sleep related breathing disorders and available evidence indicates that the routine use of the MSLT does not contribute significantly to diagnosis or assessment of response to treatment for sleep related breathing disorders and therefore is considered not medically necessary.

Multiple sleep latency test (MSLT) in the home (unattended/unsupervised) would be considered investigational as it has not been proven to be equivalent to a formal multiple sleep latency test (MSLT) performed in a sleep laboratory/facility.  

 

Repeat Testing Multiple Sleep Latency Test (MSLT)

 

Repeat multiple sleep latency test (MSLT) for all other indications 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.

 

The following tests and treatments for OSA are considered investigational (not an all inclusive list):
Actigraphy

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.

Sleep Strip

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.

Oral Pressure Therapy (OPT)/the WINX therapy system

No full length, peer reviewed studies on oral pressure therapy have been identified in the published literature. Therefore, it is not possible to evaluate the efficacy of this treatment based on scientific evidence and therefore 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.

  • 94762 Noninvasive ear or pulse oximetry for oxygen saturation by continuous overnight monitoring
  • 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 Health Technology Information ServiceExternal Site 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 proceduresExternal Site an update for 2005. Accessed Nov 12, 2008.
  • Institute for Clinical Systems ImprovementExternal Site (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 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. Auto-titrating Continuous Positive Airway Pressure (Auto-CPAP) versus Fixed Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI InstituteExternal Site 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 InstituteExternal Site 2010 Jan 07. 13 p. [ECRI hotline response]. Also available: 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 QualityExternal Site (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 InstituteExternal Site 2011 November 14. [Hotline Service].
  • ECRI. Ambulatory/Portable Sleep Apnea Monitors for Diagnosis of Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI InstituteExternal Site 2011 June 22. [Hotline Service].
  • ECRI. Autotitrating versus Fixed Continuous Positive Airway Pressure for Treating Obstructive Sleep Apnea. Plymouth Meeting (PA): ECRI InstituteExternal Site 2011 November 1. [Hotline Service].
  • ECRI. Actigraphy for the Evaluation of Sleep Disorders. Plymouth Meeting (PA): ECRI InstituteExternal Site 2011 July 18. [Hotline Service].
  • Crowley, K. E., et al. "Evaluation of a single-channel nasal pressure device to assess obstructive sleep apnea risk in laboratory and home environments." Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 9.2 (2013): 109-116.
  • Chen H, Lowe AA. Updates in oral appliance therapy for snoring and obstructive sleep apnea. Sleep Breath. 2012 May 6. [Epub ahead of print]. Accessed 3/26/13.
  • 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. Rosen CL, Auckley D, Benca R, Foldvary-Schaefer N, ..., Kapur V, Rueschman M, Zee P, Redline S.  Sleep. 2012; 35(6):757-67
  • 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 MedicineExternal Site (AASM) Clarifies Hypopnea Scoring Criteria, September 23, 2013. AASM News Archives.
  • American Academy of Sleep MedicineExternal Site (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 MedicineExternal Site (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.
  • UpToDateExternal Site Clinical Presentation and Diagnosis of Obstructive Sleep Apnea in Adults. Lewis R. Kline, M.D.. Topic last updated December 9, 2013.
  • UpToDateExternal Site Sleep Related Breating Disorders in Adults. Definitions. Kingman P. Strohl M.D., Topic last updated January 29, 2013.
  • UpToDateExternal Site Portable Monitoring in Obstructive Sleep Apnea in Adults. Nancy Collop, M.D., Topic last updated February 19, 2014.
  • UpToDateExternal Site 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
  • UpToDateExternal Site 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
  • UpToDateExternal Site 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.
  • ECRIExternal Site Hotline Response. Continuous Positive Airway Pressure for Treating Obstructive Sleep Apnea July 2014.
  • ECRIExternal Site 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
  • 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 PhysiciansExternal Site 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 MedExternal Site Sept 2013; 159(7):471-83.
  • American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. Peri-operative Management of Obstructive Sleep ApneaExternal Site Surg Obes Relat Dis. 2012 May-Jun;8(3):e27-32.
  • National Institute for Health and Clinical Excellence. NICE technology appraisal guidance 139External Site Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome. 2010.
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Policy History:

  • 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.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.