The following guidelines should be applied to services performed in conjunction with sleep related conditions:

Diagnostic Evaluation of Sleep-Related Disorders

Sleep Studies and Polysomnography (95805-95811)
Sleep studies and polysomnography 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 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 (95808-95811). Therefore, separate payment should not be made for these parameters when reported with a polysomnogram on the same day by the same provider.

Polysomnographies are generally performed on consecutive dates of service. Payment may be allowed for a maximum of two (2) six-hour polysomnographies per diagnostic/treatment period for the following diagnoses:

Sleep Apnea: 770.81, 770.82, 780.51, 780.53, 780.57
Narcolepsy or hypersomnia: 307.43-307.44, 347.00, 347.01, 347.10, 347.11, 780.53-780.54, 780.58
Myoclonus or restless leg syndrome: 333.2, 333.99

The following conditions are subject to medical review:

Insomnia: 307.41-307.42, 780.50, 780.51-780.52 (payable only when the physician suspects sleep apnea)
Sleepwalking: 307.46 (payable only when the physician suspects nocturnal epilepsy)
Night Terrors: 307.46 (payable only when the physician suspects nocturnal epilepsy)
Enuresis: 788.36, 788.38 (payable only when the physician suspects nocturnal epilepsy)

When warranted by the patient's symptoms, payment may be made for polysomnograms performed to "rule out" the conditions/diagnoses specified in the preceding guidelines.

For a study to be reported as polysomnography (95808, 95810, 95811), sleep must be recorded and staged. A sleep study which includes 3 or more parameters of sleep other than sleep staging (95807) is not a polysomnogram. When a polysomnogram (95808, 95810, 95811) and a sleep study (95807) are performed on the same day, the charges should be combined with the appropriate polysomnography code.

Sleep studies and polysomnograms (95807-95811) are complex studies which measure multiple physiological parameters. Sleep is a highly dynamic state and the quality of the data collected can be markedly affected by dislodged probes and monitoring devices as the patient moves around in bed during sleep. The quality of data improves substantially with a technologist in constant attendance. Also, for some parameters (e.g., snoring, physical movement, body positioning, etc.) visualization is necessary. Therefore, unattended sleep studies (95806) and unattended polysomnograms (94799) should be denied as noncovered when performed in any place of service.

Attended sleep studies (95807) and polysomnograms performed on standard (stationary) equipment and attended by a technician (95808-95811) are eligible for payment. Polysomnograms performed on portable equipment are not covered. Currently, there is no evidence that portable polysomnogram equipment has advanced to the point where the accuracy and quality of data equal the polysomnogram performed on standard equipment.

Attended sleep studies and attended polysomnograms performed on standard equipment are eligible for payment 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.

Attended sleep studies performed in a patient's home are eligible for payment. However, attended polysomnograms performed in a patient's home are performed on portable equipment, and therefore are not eligible for payment.

Sleep studies and polysomnography (95805-95811) should not be reported when the service provided is a pediatric pneumogram. 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. See Medical Policy Bulletin E-3 for guidelines on infant apnea monitoring (E0618, E0619).

Multiple sleep latency testing (MSLT) (95805) 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. MSLT is generally performed for the diagnosis of narcolepsy.

Other Miscellaneous Services
Services other than the polysomnography which are performed in conjunction with sleep related-conditions (e.g., medical examinations and evaluations, consultations, pathology and laboratory tests, etc.) are to be handled routinely.

NOTE: See Medical Policy Bulletin E-25 for guidelines on the pulse oximetry device.

Treatment for Sleep-Related Disorders

Snoring
Medically necessary services performed for the diagnosis or direct treatment of the member's disease, illness, or injury are contractually covered. Socially disruptive snoring is not a disease, illness, or injury. Therefore, treatment solely for the correction of socially disruptive snoring is noncovered.

Obstructive Sleep Apnea (OSA)
Obstructive sleep apnea is a syndrome that results from blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. OSA is associated with loud snoring, observed apneas during sleep, and sleep fragmentation. OSA can cause excessive daytime sleepiness, cognitive and personality problems, high blood pressure and other cardiovascular disease. Predisposing risk factors include being male, overweight, a smoker, and over the age of 40. However, OSA can strike anyone at any age, even children. Adenotonsillar hypertrophy, retrognathia, hypothyroidism, nasal obstruction, evening alcohol consumption, and the use of sedatives are also risk factors for OSA. The severity of the apnea is a guide for treatment. However, due to the multifactorial nature of this disorder, each patient should be evaluated individually and their treatment planned accordingly.

• Behavior Modification - Behavior modification includes alteration of sleep position, avoidance of alcohol and sedative medication and weight-reduction programs. Avoidance of alcohol and sedative medication does not treat the OSA, it only prevents exacerbation of the existing condition. Weight reduction is potentially therapeutic, but permanent loss of significant excess body weight by behavioral means alone is rarely successful.
• Drug Therapy - Drug Therapy for OSA is of limited clinical value.
• Nasal Continuous Positive Airway Pressure (nCPAP) - nCPAP is considered the first-line treatment for most patients with OSA. Non-compliance with nCPAP is the major limitation to its effectiveness.

  NOTE: See Medical Policy Bulletin E-20 for guidelines on nCPAP.

• Intra-Oral appliances - Intra-oral appliances that affect pharyngeal mechanics by altering the relative position of the upper and lower jaws and tongue are effective in diminishing apnea in some patients.

  When a benefit, intra-oral appliances (S8260) are eligible for the treatment of diagnosed obstructive sleep apnea (770.81, 770.82, 780.51, 780.53, 780.57) for patients who have failed nCPAP.

  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. A participating, preferred, or network provider cannot bill the member for the denied service. 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.

When selecting patients for surgical treatment of OSA, the level(s) of obstruction need to be identified in order to determine the appropriate procedure(s) to perform. The levels of obstruction may include one or a combination of the following regions of the upper airway: nasal, nasopharynx, oropharynx, hypopharynx. The staged approach to surgical treatment based on the level(s) of obstruction is generally accepted as the standard of care. However, for select patients with multilevel obstruction as noted on presurgical examination, more than one surgical procedure may be required, either combined or staged. There are no universally accepted “stages” of surgical treatment. The staged approach is individualized based upon each patient and their symptoms, in addition to their physical findings. For most patients, the staged approach is acceptable if the patient is advised at the onset of treatment about the likelihood of success of each procedure and that multiple operations may be necessary.

The following surgical procedures (combined or staged) are available for the treatment of OSA. (This is not an all-inclusive list.)

Septoplasty (30520)
Turbinectomy (30130, 30140)
Polypectomy (31237)
Adenoidectomy (42830-42836)
Tonsillectomy (42820-42826)
Uvulopalatopharyngoplasty (UPPP) or palatopharyngoplasty (PPP) (42145)
* Laser-assisted uvulopalatoplasty (LAUP) (S2080)
* Laser-assisted tonsillectomy or laser ablation of the tonsils (LAT) (42999)
* Radiofrequency reduction of the soft palate and/or tongue base (Somnoplasty) (0088T)
Partial glossectomies (41120, 41130)
Inferior sagittal mandibular osteotomy (21121-21123) and genioglossal advancement (21299)
Hyoid myotomy and suspension (21685)
Maxillomandibular osteotomy and advancement (21141-21147, 21195, 21196, 21199)
Tracheostomy (31600)

*The following guidelines apply to LAUP, LAT, and Somnoplasty performed for the treatment of obstructive sleep apnea.

Laser-assisted uvulopalatoplasty (LAUP)(S2080) is a procedure performed with a carbon dioxide laser to progressively enlarge the oropharyngeal air space by trimming and reshaping the uvula, free edge of the soft palate, and pharyngeal pillars. LAUP is performed sequentially over several outpatient settings under local anesthesia. LAUP is a distinct procedure and does not refer to the use of the laser as a tool in performing UPPP. LAUP is covered for patients with obstructive sleep apnea, documented by polysomnography, who require a palatal procedure. Payment will be made for LAUP on a per session basis.

Laser ablation of the tonsils or laser-assisted tonsillectomy (LAT)(42999) may be performed in conjunction with LAUP for the treatment of obstructive sleep apnea. The laser is also used as a surgical tool in an otherwise standard tonsillectomy and to vaporize the surface of the tonsils (i.e., cryptolysis or subtotal tonsillectomy). LAT performed with LAUP for the treatment of documented obstructive sleep apnea is a covered procedure. Payment will be made for both LAUP (S2080) and LAT (42999) subject to multiple surgery guidelines on a per session basis. LAT (42999) is also covered when the laser is used as a surgical tool for a standard tonsillectomy. LAT is considered experimental/investigational and not covered when the laser is used to vaporize the surface of the tonsils (i.e., cryptolysis or subtotal tonsillectomy). A participating, preferred, or network provider can bill the member for the denied service. Scientific evidence does not demonstrate that this procedure is as effective as a tonsillectomy.

Radiofrequency ablation of the soft palate and/or tongue base (e.g., Somnoplasty) (0088T) is a minimally invasive, outpatient procedure which reduces and tightens excess tissue in the upper airway. Typically more than one procedure is necessary to achieve optimal results. Radiofrequency ablation of the soft palate and tongue base for the treatment of obstructive sleep apnea is experimental/investigational and not covered. A participating, preferred, or network provider can bill the member for the denied service. Studies have been non-randomized and non-controlled. Somnoplasty is still being performed in a clinical trial setting with no long-term outcomes available. (See Medical Policy Bulletin S-136 for guidelines on radiofrequency ablation of the nasal turbinates for nasal obstruction.)

NOTE:

LAUP, LAT, and Somnoplasty performed solely for the treatment of socially disruptive snoring should be denied as contractually noncovered. See guidelines under snoring.

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.

Managed Care

When a PCP must refer a member to a dentist for an intra-oral appliance, every effort should be made to refer the member to a Blue Shield participating dentist.

PRN References

08/1993, Polysomnograms, reporting
03/1994, Laser-assisted palatopharyngoplasty, reporting of
10/1995, Laser-assisted palatopharyngoplasty, codes and reimbursement for
08/1994, Sleep studies and polysomnograms, reporting of
02/1998, Coverage dropped for laser-assisted uvulopalatoplasty, laser ablation of the tonsils
04/1998, Coverage of sleep studies and polysomnograms outlined
08/1998, Reporting guidelines for polysomnograms clarified
10/1999, Coverage for intra-oral appliances for the treatment of obstructive sleep apnea outlined 10/1999, Reporting polysomnograms, pneumograms, and infant apnea monitors clarified
08/2000, Radiofrequency ablation of the soft palate and/or tongue base not covered
12/2000, Laser-assisted uvulopalatoplasty (LAUP) approved for treatment of obstructive sleep apnea

Practice Parameters for the Treatment of Obstructive Sleep Apnea in Adults: The Efficacy of Surgical Modifications of the Upper Airway, American Sleep Disorders Association and Sleep Research Society, Sleep, Volume 19, No. 2, 1996

Laser-Assisted Uvulopalatoplasty for the Treatment of Mild, Moderate, and Severe Obstructive Sleep Apnea, Laryngoscope, Volume 109, No. 1, 1999

Short-Term Objective and Long-Term Subjective Results of Laser-Assisted Uvulopalatoplasty for Obstructive Sleep Apnea, Laryngoscope, Volume 109, No. 3, 1999

Efficacy of Laser-Assisted Uvulopalatoplasty in Obstructive Sleep Apnea, Otolaryngology - Head and Neck Surgery, Volume 119, No. 6, 1998

A Multi-Institutional Study of Radiofrequency Volumetric Tissue Reduction for OSAS, Otolaryngology - Head and Neck Surgery, Volume 125, No. 4, 10/2001

Combined Temperature-Controlled Radiofrequency Tongue Reduction and UPPP in Apnea Surgery, ENT - Ear, Nose & Throat Journal, Volume 8, No. 9, 09/2001

Complications of Radiofrequency Ablation in the Treatment of Sleep-Disordered Breathing Otolaryngology - Head and Neck Surgery, Volume 125, No. 5, 11/2001

Comparison Postoperative Pain Between Laser-Assisted Uvulopalatoplasty (LAUP), Uvulopalatopharyngoplasty (UPPP), and Radiofrequency Volumetric Tissue Reduction of the Palate (RFVTR), Otolaryngology - Head and Neck Surgery, Volume 122, No. 3, 03/2000