Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: Z-8-051
Topic: Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
Section: Miscellaneous
Effective Date: January 1, 2017
Issue Date: January 23, 2017
Last Reviewed: September 2016

According to the American Academy of Sleep Medicine (AASM), the signs, symptoms and consequences of Obstructive Sleep Apnea (OSA) are a direct result of the imbalances that occur due to repetitive collapse of the upper airway: sleep fragmentation, hypoxemia, hypercapnia, marked swings in the intra-thoracic pressure, and increased sympathetic activity. Clinically, OSA is defined by the occurrence of daytime sleepiness, loud snoring, witnessed breathing interruptions, or awakenings due to gasping or choking in the presence of at least 5 obstructive respiratory events (apneas, hypopneas or respiratory effort related arousals) per hour of sleep. The presence of 15 or more obstructive respiratory events per hour of sleep in the absence of sleep related symptoms is also sufficient for the diagnosis of OSA due to the greater association of this severity of obstruction with important consequences such as increased cardiovascular disease risk.

The use of polysomnography (PSG) for evaluating OSA requires recording the following physiologic signals: electroencephalogram (EEG), electrooculogram (EOG), chin electromyogram, airflow, oxygen saturation, respiratory effort, and electrocardiogram (ECG) or heart rate. Additional recommended parameters include body position and leg electromyography (EMG) derivations. Anterior tibialis EMG is useful to assist in detecting movement arousals and may have the added benefit of assessing periodic limb movements, which coexist with sleep-related breathing disorders (SRBD) in many patients.

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Diagnosis of Obstructive Sleep Apnea
The diagnosis of OSA is based upon the presence or absence of related symptoms, as well as the frequency of respiratory events during sleep (e.g., apneas, hypopneas, and respiratory effort related arousals [RERAs]) as measured by polysomnography or out-of-center sleep testing (OCST). In adults, the diagnosis of OSA is confirmed if EITHER of the following conditions exists:

An obstructive apnea is defined as at least a 10-second cessation of respiration associated with ongoing ventilatory effort.  Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared with baseline, and with at least a 4% oxygen desaturation.

OSA severity classification is based on two (2) measures:

·         Respiratory disturbance index (RDI):

o    Includes the total number of apneas, hypopneas, and respiratory effort related arousal (RERA) during sleep, divided by the hours of sleep observed

·         Apnea/hypopnea index (AHI):

o    Includes the total number of apneas and hypopneas recorded during sleep, divided by the hours of sleep recorded

An apnea/hypopnea index (AHI) greater than 5 is considered abnormal an AHI greater than 30 is considered severe.

OSA severity classification:

Diagnostic Testing

Out-of-Center Sleep Testing (OCST)/Portable Monitoring (PM) Unattended Sleep Studies
A single OCST/PM unattended sleep study with a minimum of four (4) recording channels (including oxygen saturation, respiratory movement, airflow, and EKG or heart rate) may be considered medically necessary for:

Note: This statement does not imply that attended studies are needed routinely following unattended studies. This statement means a re-evaluation based on a substantial change in symptoms or in the clinical situation.

OCST/PM unattended sleep studies are considered experimental/investigational and therefore non-covered in adult patients who do not meet any of the above criteria as they would be considered at low risk for OSA.

OCST/PM unattended sleep studies performed in the patient’s home must be interpreted by a physician who is either:

The performance of multiple nights of OCST/PM unattended sleep studies are recognized as one (1) study. The performance of multiple night testing has been shown to address (a) night-to-night variability, (b) first night effect, and (c) failed studies. However, as multiple night testing is performed as part of a single episode of testing, OCST/PM Unattended sleep studies will be paid as one (1) service regardless of the number of multiple nights of patient data obtained to successfully and appropriately complete the testing.

OCST/PM unattended sleep studies are reported with a service of one (1) for the entire episode of testing. The date of service is reported as the date the study is completed.

 

Procedure Codes

95800, 95801, 95806, G0398, G0399, G0400

 

Facility/Laboratory Attended Sleep Studies
Attended polysomnography with a minimum of 7 recording channels (including electroencephalography (EEG), electrooculogram (EOG), chin electromyography (EMG), electrocardiogram (ECG) or heart rate, airflow, respiratory effort, oxygen saturation) performed in a sleep laboratory may be considered medically necessary as a diagnostic test in patients for the following indications:

 

*If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA, (e.g., age of the patient, male gender, thick neck [greater than 17 inches in men, and greater than 16 inches in women], or craniofacial or upper airway soft tissue abnormalities) may be considered.

and

Attended polysomnography with a minimum of 7 recording channels (including EEG, EOG, chin EMG, ECG or heart rate, airflow, respiratory effort, oxygen saturation) performed in a sleep laboratory may be considered medically necessary as a diagnostic test in:

Note: This statement does not imply that attended studies are needed routinely following unattended studies. This statement means a re-evaluation based on a substantial change in symptoms or in the clinical situation.

For CPAP initiation and titration, a split-night study (initial PSG followed by CPAP titration during PSG on the same night) is an alternative to one full night of PSG followed by a second night of titration when ALL three (3) of the following criteria are met:

*A second full night PSG should be performed for titration of positive airway pressure if the second and third criteria listed above are not met.

Notes:

“Split-night” services (initial diagnostic polysomnography (PSG) followed by continuous positive airway pressure (CPAP) titration during PSG on the same night) that last at least five (5) hours are to be reported with procedure code 95811. “Split-night” services less than five (5) hours are to be reported as 95811 with modifier 52.

The use of an abbreviated cardiorespiratory daytime sleep study (PAP-NAP) as a supplement to standard sleep studies or to acclimatize an individual to PAP is considered experimental/investigational and therefore non-covered due insufficient evidence to determine the effects of the technology on health outcomes.

PAP-NAP studies are to be reported as 95807 with modifier 52.

Procedure Codes

94799, 95807, 95808, 95810, 95811

 

REPEAT SLEEP STUDIES

Repeat OCST/PM Unattended Sleep Study 
Repeated OCST/PM Unattended sleep studies with a minimum of 4 recording channels (including oxygen saturation, respiratory movement, airflow, and EKG/heart rate) may be considered medically necessary in adult patients for in EITHER of the following circumstances:

Multiple consecutive nights of attended or unattended sleep studies that do not meet the above criteria for repeat studies are considered not medically necessary.

Repeat Facility/Laboratory Attended Sleep Studies
A repeat supervised polysomnography performed in a sleep laboratory may be considered medically necessary for ANY ONE of the following circumstances:

Note: This statement does not imply that supervised studies are needed routinely following unattended studies. This statement means a re-evaluation based on a substantial change in symptoms or in the clinical situation.

Procedure Codes

G0398, G0399, G0400, 94799, 95800, 95801, 95806, 95807, 95808, 95810, 95811

Multiple Sleep Latency Test (MSLT)
Multiple sleep latency testing is considered not medically necessary in the diagnosis of OSA except to exclude or confirm narcolepsy in the diagnostic workup of OSA syndrome.

The MSLT are not routinely indicated in the evaluation and diagnosis of OSA or in assessment of change following treatment with CPAP. The MSLT may be indicated as part of the evaluation of patients with suspected narcolepsy to confirm the diagnosis (often characterized by cataplexy, sleep paralysis, and hypnagogic/hypnopompic hallucinations) or to differentiate between suspected idiopathic hypersomnia and narcolepsy. Narcolepsy and OSA can co-occur. Since it is not possible to differentiate the excessive sleepiness caused by OSA and narcolepsy, the OSA should be treated before confirming a diagnosis of narcolepsy with the MSLT.

Maintenance of Wakefulness Test (MWT)
The maintenance of wakefulness test is considered experimental/investigational for ALL indications and therefore non-covered due to insufficient evidence in the peer-reviewed published medical literature regarding its effectiveness. 

Actigraphy
Actigraphy is considered experimental/investigational and therefore non-covered when used as the sole technique to record and analyze body movement, including but not limited to its use to evaluate sleep disorders. This does not include the use of actigraphy as a component of portable sleep monitoring. When used as a component of portable sleep monitoring, actigraphy should not be separately reported. 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.

 

Procedure Codes

95803, 95805

 

MEDICAL TREATMENT

Snoring
Socially disruptive snoring is not a disease, illness, or injury. Therefore, treatment solely for the correction of socially disruptive snoring is considered not medically necessary.

Behavior Modification
Behavioral treatment options include weight loss, ideally to a body mass index (BMI) of 25 kg/m2 or less; exercise; positional therapy; and avoidance of alcohol and sedatives before bedtime. Regardless of behavioral approach, general OSA outcomes should be assessed after initiation of therapy in all patients. 

Successful dietary weight loss may improve the AHI in obese patients with OSA. After substantial weight loss (i.e., 10% or more of body weight), a follow-up PSG may be considered medically necessary:

The follow-up PSG is routinely indicated to ascertain whether PAP therapy is still needed or whether adjustments in PAP level are necessary.

Note: This statement does not imply that attended studies are needed routinely following unattended studies. This statement means a re-evaluation based on a substantial change in symptoms or in the clinical situation. 

Drug Therapy

Drug Therapy for OSA is of limited clinical value. 

Continuous Positive Airway Pressure (CPAP)

See Medical Policy Bulletin E-20 for guidelines on devices used for the treatment of obstructive sleep apnea in adults. 

Intra-Oral Appliances

See Medical Policy Bulletin E-20 for guidelines on devices used for the treatment of obstructive sleep apnea in adults. 

SURGICAL TREATMENT

Uvulopalatopharyngoplasty (UPPP) may be considered medically necessary for the treatment of clinically significant* OSA in appropriately selected adult patients who have not responded to or do not tolerate nasal CPAP. 

Note: A tonsillectomy is considered an integral component of UPPP and is not separately reimbursed.

Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA) may be considered medically necessary in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP or failed use of an oral appliance (OA). 

Surgical treatments, including but not limited to the following, may be considered medically necessary for the treatment of OSA:

The following surgical treatments may be considered medically necessary for the adjunctive treatment of OSA:

*Clinically significant OSA is defined as those patients who have:

Surgical treatment of OSA that does not meet the criteria above is considered not medically necessary.

Implantable hypoglossal nerve stimulators (64568, 0466T, 0467T and 0468T) are considered experimental/investigational and therefore non-covered for the treatment of adult OSA due to insufficient evidence in the peer-reviewed published medical literature regarding its effectiveness and safety.

The following minimally-invasive surgical procedures for the treatment of OSA are considered experimental/investigational and therefore non-covered due to lack of evidence regarding net health outcomes. 

Due to of the likelihood of adverse effects, surgery should be limited to patients who are unable to tolerate CPAP. Minimally invasive surgical procedures have limited efficacy in patients with mild to moderate OSA and have not been shown to improve AHI or excessive daytime sleepiness in adult patients with moderate to severe OSA. These are considered experimental/investigational and therefore non-covered. 

Note: All interventions, including but not limited to LAUP, laser-assisted tonsillectomy or laser ablation of the tonsils (LAT), radiofrequency volumetric tissue reduction of the palate, palatal stiffening procedures and tongue based suspension procedures are considered not medically necessary for the treatment of snoring in the absence of documented OSA; snoring alone is not considered a medical condition.

Procedure Codes

0466T, 0467T, 0468T, 21121, 21122, 21123, 21195, 21196, 21199, 21299, 21685, 30130, 30140, 30520, 31237, 31600, 41120, 41130, 41512, 41530, 42140, 42145, 42821, 42826, 42831, 42835, 42836, 42999, 64568, S2080

 

Professional Statements and Societal Positions

American Academy of Sleep Medicine (AASM) Guidelines of Monitoring Devices:

Type I (at least 7 channels)
Monitoring devices performed in-laboratory, technician-attended, overnight polysomnography (PSG).

Type II (at least 7 channels)
Monitoring devices can perform full PSG outside of the laboratory. The major difference from type 1 devices is that a technologist is not present. These devices are called comprehensive portable devices.

Type III (at least 4 channels)
Monitoring devices do not record the signals needed to determine sleep stages or sleep disruption. Typically channels include:

  • Four physiologic variables are measured including:
  • Two respiratory variables (e.g., respiratory movement and airflow)
  • Cardiac variable (e.g., heart rate or an electrocardiogram)
  • Arterial oxygen saturation
  • Some devices may have other signals including a monitor to record snoring; detect light, or a means to determine the body position.

Type IV (at least 2 channels)
These devices are called continuous single or dual bioparameter devices. Monitoring devices record one or two variables and can be used without a technician. Typically channels include:

  • Arterial oxygen saturation
  • Airflow

Type IV monitors with fewer than 3 channels is not recommended due to reduced diagnostic accuracy and higher failure rates.

Technology Used in Portable Monitoring

  • Oximetry
  • Respiratory monitoring, including but not limited to:
    • Effort
    • Airflow
    • Snoring
    • End-tidal CO2 
    • Esophageal pressure
  • Cardiac monitoring, including but not limited to:
    • Heart rate or heart rate variability 
    • Arterial tonometry
  • Measures of sleep wake activity, including but not limited to:
    • Electroencephalography
    • Actigraphy
  • Body position

Refer to additional information attachment.


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Diagnosis and Treatment of Obstructive Sleep Apnea for Adults is typically an outpatient procedure which is only eligible for 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.



The policy position applies to all commercial lines of business


FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A 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.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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