Obstructive sleep apnea syndrome in children is a disorder of breathing during sleep, characterized by prolonged partial upper airway obstruction and/or intermittent and complete obstruction, which may be accompanied by hypoxia, hypercapnia and disturbed sleep. It occurs in approximately 2% of children at a peak of 2 to 6 years of age (habitual snoring occurs in 3% to 12% of preschool age children).  Furthermore, premature infants and children with other conditions including craniofacial disorders, obesity, neuromuscular disorders, Down syndrome, chronic lung disease, sickle cell anemia, central hypoventilation syndromes, and a number of other genetic and metabolic diseases are at higher risk of sleep-disordered breathing. Obstructive sleep apnea syndrome can result in serious morbidity, including neurocognitive disorders such as poor learning, behavioral problems, and attention-deficit/hyperactivity disorder, failure to thrive, cor pulmonale, and even death if untreated in more severe cases. In addition, there are high economic costs of untreated OSAS in children.

NOTE:

A child is defined as one (1) through seventeen (17) years of age.

Diagnosis
Sleep studies (95805-95807) and polysomnography (95808-95811) refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for six or more hours with physician review, interpretation and report.

Polysomnography (95808-95811) is distinguished from other sleep studies by the inclusion of sleep staging which is defined to include a 1 to 4 lead electroencephalogram (EEG), electro-oculogram (EOG), and submental electromyogram (EMG). Additional parameters that can be measured during sleep may include:

ECG
Airflow
Ventilation and respirator effort
Gas exchange by oximetry, transcutaneous monitoring, or end tidal gas analysis
Extremity muscle activity, motor activity-movement
Extended EEG monitoring
Penile tumescence
Gastroesophageal reflux
Continuous blood pressure monitoring
Snoring
Body positions; etc.

An EEG, EOG, EMG, EKG, and oximetry are the most common parameters of sleep measured during a polysomnogram. Therefore, separate payment should not be made for these parameters when reported with a polysomnogram on the same day by the same provider.

Attended polysomnography (95808-95811) performed on standard equipment is the diagnostic test of choice for the pediatric patient because it is the only technique shown to quantify the ventilatory and sleep abnormalities associated with sleep-disordered breathing.

Polysomnography is covered for children and adolescents younger than 18 years of age when performed in the following locations:

• In-hospital (tests performed on patients who are admitted as overnight bed patients in a hospital)
• Outpatient (including locations owned or controlled by a hospital)
• Office (including sleep labs or sleep clinics)

NOTE:

Office place of service should only be reported when all technical costs (technicians, equipment, and office overhead) associated with the polysomnograms are the responsibility of the billing physician.

Polysomnography for children is covered for any of the following indications:

• differentiation of benign or primary snoring from pathological snoring
• evaluation of disturbed sleep patterns, excessive daytime sleepiness, cor pulmonale, failure to thrive, or polycythemia unexplained by other factors or conditions
• when physician is uncertain whether clinical observation of obstructed breathing is sufficient to warrant surgery
• to determine whether child needs intensive postoperative monitoring following adenotonsillectomy or other pharyngeal surgery
• child previously diagnosed with OSA who exhibits persistent snoring or other symptoms of sleep disordered breathing despite therapy
• titration of continuous positive airway pressure (CPAP) levels

Polysomnography for children is considered not medically necessary for the following:

• Sleep walking or night terrors; 
• Routine evaluation of adenotonsillar hypertrophy alone without other clinical signs or symptoms suggestive of obstructive sleep disordered breathing; 
• Routine follow-up for children whose symptoms have resolved post-adenotonsillectomy unless the pre-operative RDI or AHI was greater than 19 or the child continues to snore post-operatively or other symptoms related to pre-operative sleep disordered breathing persist or recur.

Repeat polysomnography for children is considered medically necessary in the following circumstances:

• Initial polysomnography is inadequate or non-diagnostic and the accompanying caregiver reports that the child's sleep and breathing patterns during the testing were not representative of the child's sleep at home; OR
• A child with previously diagnosed and treated obstructive sleep apnea who continues to exhibit persistent snoring or other symptoms of sleep disordered breathing. In the case of adenotonsillectomy, repeat polysomnography should also be performed if the pre-operative obstructive sleep apnea was severe (RDI or AHI greater than 19). [If the treatment was surgical, testing should be deferred for 6 to 8 weeks post-operatively]; OR
• To periodically re-evaluate the appropriateness of continuous positive airway pressure (CPAP) settings based on the child's growth pattern or the presence of recurrent symptoms while on CPAP; OR
• If obesity was a major contributing factor and significant weight loss has been achieved, repeat testing may be indicated to determine the need for continued therapy.

Repeat polysomnography is considered not medically necessary in the follow-up of patients with obstructive sleep apnea treated with CPAP when symptoms attributable to sleep apnea have resolved.

The following techniques to diagnose obstructive sleep apnea in children are considered investigational.  More randomized-controlled studies are necessary in order to establish the effectiveness of these tests.  A participating, preferred, or network provider can bill the member for the denied test.  (Note: This is not an all-inclusive list.)

• Unattended sleep studies (G0400,95800, 95801) and unattended portable polysomnograms (95806, G0398, G0399) are not eligible for the diagnosis of obstructive sleep apnea in the pediatric patient. Unattended studies in children using commercially available 4 to 6-channel recording equipment has not been studied. Portable monitoring based only on oximetry is inadequate for identifying OSA in otherwise healthy children. (Note: See Medical Policy Bulletin E-25 for guidelines on the pulse oximetry device [E0455].)
• Sleep studies – Polysomnography (95808-95811) is the only technique shown to quantify the ventilatory and sleep abnormalities associated with sleep-disordered breathing in children. For a study to be reported as polysomnography, sleep must be recorded and staged. A sleep study which includes 3 or more parameters of sleep other than sleep staging is not a polysomnogram. Therefore, sleep studies (95807) are not covered for diagnosing OSA in children. 
• Multiple sleep latency testing (95805): Multiple sleep latency testing (MSLT) consists of physiological measurements of sleep during a series of 20 minute naps at two-hour intervals performed four to five times in an eight-hour period. 
• Other Miscellaneous Services - Other abbreviated or screening techniques, such as audio taping and videotaping, daytime nap polysomnography, questionnaires (clinical assessment), and radiological evaluation (e.g., MRI) have not been proven to be effective in diagnosing OSA in children.

Sleep studies and polysomnography (95805-95811) should not be reported when the service provided is a pediatric pneumogram (94772). A pediatric pneumogram (94772) provides 12- to 24-hour continuous recording of an infant's respiratory pattern. The parameters measured may include heart and respiratory rate, oxygen saturation, and/or nasal airflow. A pediatric pneumogram (94772) should not be reported when the service provided is an infant apnea monitor with event recording.

Treatment

Medical Treatment 

• Behavior Modification - Behavior modification includes avoidance of environmental tobacco smoke and other indoor pollutants, avoidance of indoor allergens, and treatment of accompanying rhinitis. In obese patients, weight loss strategies should be used. 
• Drug Therapy - The success of pharmacological treatment of OSAS in children has not been evaluated in controlled clinical trials and therefore is considered investigational. A participating, preferred or network provider can bill the member for the denied service.
• Continuous Positive Airway Pressure (CPAP) (E0601) – CPAP is covered for treating children with OSA for patients with surgical contraindications, minimal adenotonsillar tissue, or persistent OSA after adenotonsillectomy, when definitive surgery is indicated but must await complete dental and facial development, or for those who prefer nonsurgical alternatives. Treatment with CPAP under all other circumstances and indications is considered not medically necessary.

  See Medical Policy Bulletin E-50 for additional guidelines on CPAP for treating OSA in children.

• Intra-Oral appliances (E0485, E0486) - When a benefit, intra-oral appliances are eligible for the treatment of diagnosed obstructive sleep apnea for pediatric patients with craniofacial anomalies with signs and symptoms of OSA. However, intra-oral appliances for treating OSA in patients who do not have craniofacial anomalies is considered investigational. A participating, preferred, or network provider may bill the patient for the denied appliance.
  
  There are many different types of appliances that basically fit into one of two categories, tongue retaining appliances, and mandibular repositioning appliances. Payment may be made for one appliance. Additional appliances should be denied as not medically necessary. However, replacement of the appliance is covered in case of loss or irreparable damage or wear when required because of a change in the patient's condition. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

Surgical Treatment

Covered Surgical Treatment

• Adenotonsillectomy (42820, 42821) – The vast majority of children with OSA have hypertrophy of the tonsils and adenoids. The first-line surgical treatment therefore is adenotonsillectomy.
• Other surgical options available for patients not responding to usual treatment include uvulopharyngopalatoplasty (42145), craniofacial surgery, and in severe cases, tracheostomy (31600, 31601).

Non-covered Surgical Treatment

All other surgical interventions are considered investigational for the treatment of OSA in children including, but not limited to, the following procedures. A participating, preferred or network provider can bill the member for the denied service.

• Uvulectomy (42145);
• Laser-assisted uvuloplasty (LAUP) (S2080);
• Somnoplasty or Coblation (41530);
• Repose System (41512);
• Injection snoreplasty;
• Cautery-Assisted Palatal Stiffening Procedure (CAPSO);
• Pillar Palatal Implant System;
• Flexible Positive Airway Pressure;
• Transpalatal advancement pharyngoplasty;
• Nasal surgery; and
• Mandibular distraction osteogenesis.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

See Medical Policy Bulletin Z-8 for guidelines on sleep-related disorders.

See Medical Policy Bulletin E-3 for guidelines on infant apnea monitoring (E0618, E0619).

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

10/2010, Guidelines for the diagnosis and treatment of obstructive sleep apnea in children explained

American Academy of Pediatrics (AAP). Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):704-712. Available at: http://www.pediatrics.org/cgi/content/full/109/4/704.

Schechter MS. American Academy of Pediatrics. Technical report: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):e69-e69. Available at: http://pediatrics.aappublications.org/cgi/content/full/109/4/e69.

Leong A. California Thoracic Society Position Paper: Assessing sleep-disordered breathing in children. Medical Section of the American Lung Association of California. Tustin, CA: 2006. Available at: http://www.thoracic.org/sections/chapters/thoracic-society-chapters/ca/publications/.

American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med. 1996;153:866-78.

Muzumdar H, Arens R. Diagnostic Issues in Pediatric Obstructive Sleep Apnea. Proc Am Thorac Soc. 2008 Feb 15;5(2):263-73.

Capdevila OS, Kheirandish-Gozal L, et. al. Pediatric Obstructive Sleep Apnea: Complications, Management, and Long-Term Outcomes. Proc Am Thorac Soc. 2008 Feb 15;5(2):274-82.

Kuhle S, Urschitz MS, et. al. Interventions for Obstructive Sleep Apnea in Children: A Systematic Review. Sleep Med Rev. 2009 Apr;13(2):123-31.

Kheirandish-Gozal, Gozal D. The Multiple Challenges of Obstructive Sleep Apnea in Children: Diagnosis. Curr Opin Pediatr. 2008 Dec;20(6):650-3.

Costa DJ, Mitchell R. Adenotonsillectomy for Obstructive Sleep Apnea in Obese Children: A Meta-Analysis. Otolaryngol Head Neck Surg. 2009 Apr;140(4):455-60.

Mitchell RB, Boss EF. Pediatric Obstructive Sleep Apnea in Obese and Normal-Weight Children: Impact of Adenotonsillectomy on Quality-of-life and Behavior. Dev Neuropsychol. 2009 Sep;34(5):650-61.

Redline S, Amin R, Beebe D, et al. The Childhood Adenotonsillectomy Trial (CHAT): rationale, design, and challenges of a randomized controlled trial evaluating a standard surgical procedure in a pediatric population. Sleep. 2011;34(11):1509-1517.

Paramasivan VK, Arumugam SV, Kameswaran M. Randomised comparative study of adenotonsillectomy by conventional and coblation method for children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2012 [Epub ahead of print].

Gasparini G, Saponaro G, Rinaldo FM, et al. Clinical evaluation of obstructive sleep apnea in children. J Craniofac Surg. 2012;23(2):387-391.

Esteller Moré E, Santos Acosta P, Segarra Isern F, et al. Long-term persistence of obstructive sleep apnoea-hypopnoea syndrome in children treated with adenotonsillectomy. Analysis of prognostic factors. Acta Otorrinolaryngol Esp. 2012;63(2):85-92.