Diagnosis and Treatment of Obstructive Sleep Apnea for Adults

Section: Miscellaneous
Effective Date: October 01, 2019
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

Description

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 five (5) obstructive respiratory events (apneas, hypopneas or respiratory effort related arousals) per hour of sleep. The presence of fifteen (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 individuals.

Criteria

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:

  • There are five (5) or more predominantly obstructive respiratory events (obstructive and mixed apneas, hypopneas, or RERAs) per hour of sleep (for polysomnography) or recording time (for out-of-center sleep test (OCST) in an individual with at least ONE of the following:
    • Sleepiness, non-restorative sleep, fatigue, or insomnia symptoms; or
    • Waking up with breath holding, gasping, or choking; or
    • Habitual snoring, breathing interruptions, or both noted by a bed partner or other observer; or
    • Hypertension, mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus; or
  • There are fifteen (15) or more predominantly obstructive respiratory events (apneas, hypopneas, or RERAs) per hour of sleep (for polysomnography) or recording time (for OCST), regardless of the presence of associated symptoms or comorbidities.

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):
    • Includes the total number of apneas, hypopneas, and RERA during sleep, divided by the hours of sleep observed
  • Apnea/hypopnea index (AHI):
    • Includes the total number of apneas and hypopneas recorded during sleep, divided by the hours of sleep recorded.

AHI greater than five (5) is considered abnormal,an AHI greater than 30 is considered severe.

OSA severity classification:

  • Mild for RDI or AHI five(5) to 15 respiratory events per hour of sleep.
  • Moderate for RDI or AHI 15 to 30 respiratory events per hour of sleep.
  • Severe for RDI or AHIgreater than 30 respiratory events per hour of sleep.

Home Sleep Study 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) OR a single OCST/PM unattended sleep study that measures peripheral arterial tone (PAT), actigraphy, oximetry, and heart rate (for example, the WatchPAT) may be considered medically necessary for:

  • Adult individuals who do not exhibit any of the co-morbid medical conditions designated for facility/laboratory attended sleep studies and are at moderate risk for OSA as evidenced by at least three (3) of the following:
    • Habitual snoring; or
    • Observed apneas*; or
    • Excessive daytime sleepiness; documented by an Epworth Sleepiness Scale greater than 10; or
    • Hypertension; or
    • As a screening tool in individuals who are scheduled for bariatric surgery and have no evidence by history or physical examination of a health condition that might alter ventilation or require alternative treatment; or
    • A body mass index (BMI) greater than or equal to 30 kg/m2or

* If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA, (e.g., age of the individual, 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.

  • Adults individuals for positive airway pressure (PAP) (e.g., continuous positive airway pressure [CPAP] or bi-level positive airway pressure [BiPAP] initiation and titration with sleep related breathing disorders with EITHER of the following proven options for titration:
    • Auto-titrating continuous positive airway pressure (APAP) devices when used in the self-adjusting mode for unattended treatment; or
    • In an unattended way to determine a fixed CPAP treatment pressure for individuals with moderate to severe OSA without significant comorbidities (e.g., including but not limited to central sleep apnea, chronic pulmonary disease, congestive heart failure, etc.); or
  • Adult individuals in order to monitor the response to non-CPAP treatments for OSA, including:
    • Evaluating response to oral appliance treatment; or
    • Evaluating for surgical treatment/upper airway surgery; or
    • Evaluation after significant weight loss.
      • After substantial weight loss (i.e., 10% or more of body weight), a follow-up PSG may be considered medically necessary to re-evaluate the diagnosis of OSA and need for continued CPAP, e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be re-titrated or possibly discontinued. 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.

OCST/PM unattended sleep studies are considered experimental/investigational and therefore non-covered in adult individuals 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 individual’s home must be interpreted by a physician who is either:

  • A diplomat of the American Board of Sleep Medicine (ABSM); or
  • Diplomat in Sleep Medicine by a member board of the American Board of Medical Specialties (ABMS); or
  • An active staff member of a sleep center or laboratory accredited by the AASM or The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations – JCAHO).

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 individual 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

G0398 G0399 G0400 95800 95801 95806

 

Facility/Laboratory Attended Sleep Studies

Attended polysomnography with a minimum of seven (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 individuals for the following indications:

  • When a previous home study was technically inadequate; or
  • Observed* apneas during sleep and a combination of at least two (2) of the following anda comorbid medical condition or comorbid sleep disorder:
    • Excessive daytime sleepiness evidenced by an Epworth Sleepiness Scale greater than 10, inappropriate daytime napping (e.g., during driving, conversation, or eating) or sleepiness that interferes with daily activities and is not explained by other conditions; or
    • Habitual* snoring, or gasping/choking episodes associated with awakenings; or
    • Hypertension; or
    • Obesity, defined as a body mass index (BMI) greater than or equal to30kg/m2or
    • Craniofacial or upper airway soft tissue abnormalities, including adenotonsillar hypertrophy or neuromuscular disease (e.g., Parkinson’s disease, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis (ALS); or
    • Screening individuals scheduled for bariatric surgery.

*If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA, (e.g., age of the individual, 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

  • Comorbid Medical Conditions:
    • Atrial fibrillation; or
    • Chronic pulmonary disease; or
    • Congestive heart failure (CHF) (if they remain symptomatic despite optimal medical management of CHF); or
    • Coronary Artery Disease; or
    • Significant tachycardia or bradycardic arrhythmias; or
    • Stroke, transient ischemic attack; or
    • Type 2 Diabetes; or
  • Comorbid Sleep Disorders:
    • Central Sleep apnea
      • A sleeping disorder in which respiratory effort is diminished or absent in an intermittent or cyclical fashion. During PSG, a central apneic event is conventionally defined as cessation of airflow for 10 seconds or longer without an identifiable respiratory effort. In contrast, an obstructive apneic event has a discernible ventilatory effort during the period of airflow cessation; or
    • Circadian rhythm disorders; or
    • Insomnia (associated with psychiatric disorders or transient or chronic insomnia); or
    • Parasomnias:
      • Non-rapid eye movement (NREM) related parasomnias are disorders of arousal, including confusional arousals, sleepwalking, sleep terrors, and sleep related eating disorder; or
      • Rapid eye movement (REM) related parasomnias involve the intrusion of the features of REM sleep into wakefulness (e.g., sleep paralysis), exaggeration of the features of REM sleep (e.g., nightmare disorder), or failure to manifest one of the core features of REM sleep (e.g., lack of atonia as observed in REM sleep behavior disorder); or
    • Narcolepsy; or
    • Obesity hypoventilation syndrome; or
    • Periodic limb movements in sleep; or
    • Restless leg syndrome.

Attended polysomnography with a minimum of seven(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:

  • Individuals requiring positive airway pressure (CPAP or BiPAP) initiation and titration in patients with sleep related breathing disorders with the following proven option for titration:
    • Evaluation for the presence of OSA in individuals before they undergo upper airway surgery for snoring or OSA; or
    • Assessment of treatment results to evaluate response to oral appliance treatment; or
    • Surgical treatment for OSA; or
    • Resolution of OSA after significant weight loss.
      • After substantial weight loss (i.e., 10% or more of body weight), a follow-up PSG may be considered medically necessary to re-evaluate the diagnosis of OSA and need for continued CPAP, e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be re-titrated or possibly discontinued. 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.

CPAP or BiPAP Initiation and Titration

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 (1) full night of PSG followed by a second night of titration when ALL three (3) of the following criteria are met:

  • An AHI of at least 40 events per hour of sleep is documented during a minimum oftwo(2)hours of sleep. Alternatively, an AHI of 20 to 39 events per hour of sleep is documented during a minimum oftwo(2) hours of sleep and there is strong supportive evidence of OSA (e.g., repetitive long obstructions with major desaturations); and
  • Positive airway pressure titration is conducted for more thanthree (3)hours, since obstructive events can worsen as the night progresses; and
  • Elimination or near elimination of obstructive events with positive airway pressure is documented by PSG during rapid eye movement (REM) and non-REM (NREM) sleep. This should include REM sleep in the supine position, when apneas are most likely to occur.

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

Notes:

  • A split-night study, in which severe OSA is documented during the first portion of the study using polysomnography, followed by CPAP during the second portion of the study, can eliminate the need for a second study to titrate CPAP.
  • Respiratory disturbance index may be used in place of an AHI in unattended sleep studies.

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.

Procedure Codes

94799 95807 95808 95810 95811

 

REPEAT SLEEP STUDIES

Repeat OCST/PM Unattended Sleep Study

Repeated OCST/PM Unattended sleep studies may be considered medically necessary in adult individuals in EITHER of the following circumstances:

  • To assess efficacy of surgery or oral appliances/devices; or
  • To re-evaluate the diagnosis of OSA and need for continued CPAP (e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be re-titrated or possibly discontinued).

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 necessaryfor ANY ONE ofthe following circumstances:

  • To initiate and titrate continuous positive airway pressure (CPAP) in adult individuals with clinically significant OSA defined as those patients who have:
    • An AHI of at least fifteen (15) per hour; or
    • An AHI of at least five (5) per hour in a patient with excessive daytime sleepiness or hypertension.
  • Failure of resolution of symptoms or recurrence of symptoms during treatment; or
  • To assess efficacy of surgery or oral appliances/devices; or
  • To re-evaluate the diagnosis of OSA and need for continued CPAP, e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be re-titrated or possibly discontinued.

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)

MSLT 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.

Refer to medical policy M-62 Polysomnography (PSG) for Non-Respiratory Sleep Disorders for additional information.

Maintenance of Wakefulness Test (MWT)

The test MWT is considered experimental/investigational for ALLindications 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 soletechnique 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 alone does not provide a reliable measure of sleep efficiency in clinical populations.

Procedure Codes

95803 95805

 

MEDICAL TREATMENT

Behavior Modification

Behavioral treatment options include weight loss, ideally to a BMI of 25 kg/m2or 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 individuals.

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

  • To re-evaluate the diagnosis of OSA and need for continued CPAP, e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be re-titrated or possibly discontinued.

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)

Refer to medical policy Devices Used for the Treatment of Obstructive Sleep Apnea in Adults for additional information.

Intra-Oral Appliances

Refer to medical policy Devices Used for the Treatment of Obstructive Sleep Apnea in Adults for additional information.

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.

SURGICAL TREATMENT

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 individuals 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).

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

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

  • Tracheostomy

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

  • Adenoidectomy; or
  • Tonsillectomy; or
  • Adenotonsillectomy.

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

  • AHI or RDI greater than or equal to 15 events per hour; or
  • AHI or RDI greater than or equal to five(5) events and less than or equal to fourteen (14) events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

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

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.

Experimental/Investigational Procedures

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.

  • Atrial overdrive pacing
  • Laser-assisted palatoplasty (LAUP) or radiofrequency volumetric tissue reduction of the palatal tissues
  • Laser-assisted tonsillectomy or laser ablation of the tonsils (LAT)
  • Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent (CAPSO), and the implantation of palatal implants
  • Partial glossectomies
  • Polypectomy
  • Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues (e.g., Somnoplasty)
  • Septoplasty
  • Tongue base suspension (e.g., Repose™ System )
  • Turbinectomy
  • Uvulectomy
  • All other minimally-invasive surgical procedures not described above.

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

Procedure Codes

21122 21123 21195 21196 21199 21299 21685
30130 30140 30520 31237 31600 41120 41130
41512 41530 42140 42145 42821 42826 42831
42835 42836 42999 S2080

 

Hypoglossal Nerve Stimulators

Hypoglossal nerve stimulators may be considered medically necessary in adults with OSA when ALL of the following criteria are met:

  • Age greater than or equal to 22 years; and
  • AHI greater than or equal to 20 with less than 25% central apneas; and
  • CPAP failure (residual AHI greater than 20 or failure to use CPAP greater than or equal to four (4) hours per night for five (5) or more nights per week) or inability to tolerate CPAP; and
  • Body mass index less than or equal to 32 kg/m2; and
  • Non-concentric retropalatal obstruction on drug-induced sleep endoscopy.

Hypoglossal nerve stimulators may be considered medically necessary in young adults with Down syndrome and OSA under ALL the following conditions:

  • Age 18 to 21 years; and
  • AHI greater than 10 and less than 50 with less than 25% central apneas after prior adenotonsillectomy; and
  • Have either tracheotomy or be ineffectively treated with CPAP due to noncompliance, discomfort, undesirable side effects, persistent symptoms despite compliance use, or refusal to use the device; and
  • Body mass index less than or equal to the 95th percentile for age; and
  • Non-concentric retropalatal obstruction on drug-induced sleep endoscopy.

NOTE: Drug-induced sleep endoscopy (DISE) replicates sleep with an infusion of propofol. DISE will suggest either a flat, anterior-posterior collapse or complete circumferential oropharyngeal collapse. Concentric collapse decreases the success of hypoglossal nerve stimulation and is an exclusion criterion from the Food and Drug Administration.

Use of hypoglossal nerve stimulators for OSA that does not meet the criteria above is experimental/investigational and, therefore, non-covered due to insufficient evidence to determine the effects of the technology on health outcomes.

Procedure Codes

64568 64569 64570 0466T 0467T 0468T

 

Diagnosis Codes

Covered diagnosis code for procedure codes 95807, 95808, 95810, 95811.

E11.9 E13.9 E66.2 F51.01 F51.02 F51.03 F51.09
F51.11 F51.12 F51.19 F51.3 F51.4 G25.81 G45.9
G47.00 G47.10 G47.11 G47.12 G47.13 G47.14 G47.19
G47.20 G47.29 G47.30 G47.31 G47.33 G47.34 G47.36
G47.37 G47.39 G47.411 G47.419 G47.421 G47.429 G47.50
G47.51 G47.52 G47.53 G47.54 G47.59 G47.61 G47.69
I10 I25.10 I27.20 I27.21 I27.22 I27.23 I27.24
I27.89 I48.0 I48.11 I48.19 I48.20 I48.21 I48.91
I49.8 I50.20 I50.21 I50.22 I50.23 I50.30 I50.31
I50.32 I50.33 I50.40 I50.41 I50.42 I50.43 I50.9
I63.50 I63.511 I63.512 I63.513 I63.519 I63.521 I63.522
I63.523 I63.529 I63.531 I63.532 I63.533 I63.539 I63.541
I63.542 I63.543 I63.549 I63.59 I63.81 I63.89 I63.9
I67.841 I67.848 M95.4 R00.0 R00.1 R06.3 R06.83
Z68.30 Z68.31 Z68.32 Z68.33 Z68.34 Z68.35 Z68.36
Z68.37 Z68.38 Z68.39 Z68.41 Z68.42 Z68.43 Z68.44
Z68.45            

Covered diagnosis codes for procedure codes 95800, 95801, 95806, G0398, G0399.

F51.19 G47.10 G47.11 G47.12 G47.13 G47.19 G47.30
G47.33 G47.39 R63.4 Z68.35 Z68.36 Z68.37 Z68.38
Z68.39 Z68.41 Z68.42 Z68.43 Z68.44 Z68.45

Professional Statements and Societal Positions Guidelines

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 thanthree (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
  • Peripheral arterial tone

American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 2016

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in individuals who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult individualsare candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Updated Language

Links

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.