Diagnostic Testing

Home/Unattended Sleep Studies (95800, 95801, 95806, G0398, G0399, G0400)
The following is considered experimental/investigational for the diagnosis of obstructive sleep apnea (OSA) in children and adolescents younger than 18 years of age (this is not an all-inclusive list):

• Unattended home sleep studies
• Unattended portable polysomnograms
• Other Screening techniques including but not limited to the following:
  • audio taping and videotaping
  • daytime nap polysomnography
  • questionnaires (clinical assessment)
  • radiological evaluation
  • multiple sleep latency testing

A participating, preferred, or network provider can bill the member for the denied service.

Facility/Laboratory Sleep Studies

Polysomnography (95782, 95783, 95808, 95810, 95811)
Polysomnography for children and adolescents younger than 18 years of age may be considered medically necessary with ANY ONE of the following:

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

Attended polysomnography (95782, 95783, 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 for children and adolescents younger than 18 years of age is considered not medically necessary for ANY ONE of the following:

• Sleep walking or night terrors; or
• Routine evaluation of adenotonsillar hypertrophy alone without other clinical signs or symptoms suggestive of obstructive sleep disordered breathing; or 
• 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 (95782, 95783, 95808, 95810, 95811)
Repeat polysomnography for children and adolescents younger than 18 years of age may be considered medically necessary when ANY ONE of the following are met:

• 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.

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.

Sleep studies and polysomnography (95782, 95783, 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.

Multiple Sleep Latency Testing (95805)
Multiple sleep latency testing (MSLT) may be considered medically necessary in children and adolescents younger than 18 years of age for the evaluation of ANY ONE of the following after OSA has been ruled out by polysomnography:

• Narcolepsy; or
• Suspected idiopathic hypersomnia

MSLT is not medically necessary in children and adolescents younger than 18 years of age unless performed for ANY ONE of the following:

• The first test was invalid or uninterpretable; or
• The response to treatment needs to be determined; or
• The member is suspected of having more than one sleep disorder (e.g., diagnosis of OSA and member continues to have excessive daytime sleepiness despite treatment); or
• The most recent prior MSLT test was conducted 2 or more years ago.

MSLT is not medically necessary in children and adolescents younger than 18 years of age for ANY ONE of the following:

• When performed for routine diagnosis of obstructive sleep apnea; or
• For routine follow-up after treatment of sleep related disorder; or
• Portable MSLT performed in the home setting.

See Medical Policy Bulletin Z-8 for guidelines on sleep disorder services for adults.

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 OSA in children has not been evaluated in controlled clinical trials and therefore is considered experimental/investigational. A participating, preferred or network provider can bill the member for the denied service.
• Continuous Positive Airway Pressure (CPAP)(E0601)
  
  See Medical Policy Bulletin E-50 for guidelines on continuous positive airway pressure (CPAP) devices used in the treatment of obstructive sleep apnea in children.
  
  See Medical Policy Bulletin E-20 for guidelines on positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea.
• Intra-oral appliances (E0485, E0486) may be considered medically necessary for the treatment of diagnosed obstructive sleep apnea for children and adolescents younger than 18 years of age with craniofacial anomalies with signs and symptoms of OSA.
  
  Intra-oral appliances for treating OSA in patients who do not have craniofacial anomalies is considered experimental/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
The following surgical interventions may be considered medically necessary in children and adolescents younger than 18 years of age:

• Adenotonsillectomy (42820, 42821);
• Other surgical options available for patients not responding to usual treatment include:
  • uvulopharyngopalatoplasty (42145);
  • craniofacial surgery; and
  • tracheostomy (31600, 31601) in severe cases.

All other surgical interventions for the treatment of OSA, including but not limited to the following, are considered experimental/investigational in children and adolescents younger than 18 years of age:

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

See Medical Policy Bulletin Z-8 for guidelines on sleep disorder services for adults.

Services that do not meet the criteria of this policy will not be considered medically necessary. A Pennsylvania participating, preferred or network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records. Out of Network/Non-participating providers and providers located outside of Pennsylvania may be able to bill members if the service is denied.

Place of Service: Inpatient/Outpatient

The diagnosis and treatment of obstructive sleep apnea in children is typically an outpatient procedure which is only eligible or coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

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

Description

OSA in children is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.

The presentation of obstructive sleep apnea in children may differ from that of adults. Children frequently exhibit behavioral problems or hyperactivity rather than daytime sleepiness. Daytime sleepiness may occur, but is uncommon in young children. Symptoms in children may include habitual (nightly) snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems. An apnea/hypopnea index (AHI) >1 is considered abnormal (an AHI of 15 is considered severe).

OSA can occur in children of all ages, from neonates to adolescents. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders. In otherwise healthy children, OSA is usually associated with adenotonsillar hypertrophy and/or obesity.

Left untreated, OSA can result in complications, which may include neurocognitive impairment, behavioral problems, failure to thrive, and cor pulmonale, particularly in severe cases.

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.

The multiple sleep latency test (MSLT) involves multiple trials during a day to objectively assess sleep tendency by measuring the number of minutes it takes the patient to fall asleep. The patient may be instructed to lie down in a dark room, with permission or a suggestion given to sleep (MSLT) or to sit up in a dimly lit room and try to stay awake (maintenance of wakefulness test). Parameters necessary for sleep staging (including 1 to 4 channels of EEG, EOG, and chin EMG) are recorded. 

10/2010, Guidelines for the diagnosis and treatment of obstructive sleep apnea in children explained
07/2013, Multiple sleep latency testing considered medically necessary
08/2013, Place of service designation included on additional medical policies
08/2013, Multiple sleep latency testing considered medically necessary

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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/.

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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].

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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.

Wise MS, Nicholas CD, Grigg-Damberger MM, et al. Executive summary for respiratory indications for polysomnography in children:an evidenced based review. Sleep. 2011;34(3):389-398.

Aurora RN, Lamm CI, ZAK RS, et al. Practice parameters for respiratory indications for polysomnography in children. Sleep. 2011;34(3):379-88.

Marcus CL, Brooks LJ, Ward SD, et al. Diagnosis and Management if Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2012;130(3):e714-e755.