Diagnosis and Treatment of Obstructive Sleep Apnea in Children

Section: Miscellaneous
Effective Date: January 01, 2020
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

Obstructive Sleep Apnea (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.

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

Coverage for durable medical equipment (DME) is determined according to individual or group customer benefits.

Criteria

Diagnostic Criteria

Diagnosis of OSA in children is made when ALL of the following criteria are met:

  • The caregiver reports snoring, labored breathing, or obstructed breathing during the child’s sleep; and
  • The caregiver has observed one or more of the following: paradoxical inward rib cage motion during inspiration, movement arousals, diaphoresis, neck hyperextension during sleep, excessive daytime sleepiness, hyperactivity, aggressive behavior, slow growth, morning headaches, or secondary enuresis; and
  • Polysomnography (PSG) reveals one or more obstructive apneas or hypopneas per hour of sleep (i.e., an apnea hypopnea index greater than one [1] event per hour); and
  • PSG demonstrates either of the following:
    • Frequent arousals from sleep associated with increased respiratory effort, oxyhemoglobin desaturation associated with apnea, hypercapnia during sleep, or markedly negative esophageal pressure swings; or
    • Periods of hypercapnia, oxyhemoglobin desaturation, or both during sleep that are associated with snoring, paradoxical inward rib cage motion during inspiration, and either frequent arousals from sleep or markedly negative esophageal pressure swings; and
  • The child’s findings are not better explained by another sleep disorder, a medical disorder, a neurological disorder, a medication, or substance abuse.

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

Diagnostic Testing

Home/Unattended Sleep Studies
The following are considered experimental/investigational for the diagnosis of OSA in children aged one (1) through seventeen (17) years of age including but not limited to:

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

The safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

95800958019580595806G0398G0399G0400

Facility/Laboratory Sleep Studies

PSG

PSG in children aged one (1) through seventeen (17) 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 PSG 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.

PSG in children aged one (1) through seventeen (17) 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.

Repeat PSG

Repeat PSG in children aged one (1) through seventeen (17) years of age may be considered medically necessary when any ONE of the following are met:

  • Initial PSG 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 OSA who continues to exhibit persistent snoring or other symptoms of sleep disordered breathing; or
  • Six (6) to eight (8) weeks post-adenotonsillectomy or other pharyngeal surgery for OSA and severe OSA was present on pre-operative PSG (AHI or RDI greater than ten (10); or
  • Other symptoms related to pre-operative sleep disordered breathing persist or recur; or
  • To periodically re-evaluate the appropriateness of 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 PSG is considered not medically necessary in the follow-up of patients with OSA treated with CPAP when symptoms attributable to sleep apnea have resolved.

An electroencephalogram (EEG), electro-oculogram (EOG), submental electromyogram (EMG), electrocardiogram (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 PSG should not be reported when the service provided is a pediatric pneumogram.

Procedure Codes

94772957829578395807958089581095811

Multiple Sleep Latency Testing

After OSA has been ruled out by PSG, multiple sleep latency testing (MSLT) may be considered medically necessary in children aged one (1) through seventeen (17) years of age for any ONE of the following:

  • Narcolepsy; or
  • Suspected idiopathic hypersomnia; or
  • When 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 two (2) or more years ago.

MSLT is considered not medically necessary in children aged one (1) through seventeen (17) years of age for any ONE of the following:

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

Procedure Codes

95805

Positive Airway Pressure (PAP)
CPAP in children aged one (1) through seventeen (17) years of age may be considered medically necessary in ANY of the following situations:

  • In whom adenotonsillectomy is contraindicated; or
  • Who have OSA with minimal adenotonsillar tissue; or
  • Have persistent OSA despite adenotonsillectomy; or
  • For whom there is a strong preference for a nonsurgical approach.

When the above criteria are met, payment will be made for the rental of a CPAP device for the first three (3) months from the original start date of therapy. After children have been using a CPAP device for three (3) months are found to be maintaining compliance with its use, and are experiencing success in treatment, payment will be made for the purchase of the device (after the expenses incurred for the first three [3] month’s rental have been applied to the purchase price). Compliance is defined as CPAP use of greater than four (4) hours per night of use and greater than or equal to five (5) nights per week, supported by meter readings via built-in monitoring chip.

Note: Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

Procedure Codes

E0601E0618E0619

Intra-oral Appliances

  • Intra-oral appliances may be considered medically necessary for the treatment of OSA in children aged one (1) through seventeen (17) years of age with craniofacial anomalies.

Intra-oral appliances for treating OSA in children aged one (1) through seventeen (17) years of age who do not have craniofacial anomalies are considered experimental/investigational. The safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Payment may be made for only one appliance. Additional appliances are considered not medically necessary. Replacement of the appliance is covered in case of loss or irreparable damage or wear when necessary due to a change in the member’s condition. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

Procedure Codes

E0485E0486

Surgical Treatment

The following surgical interventions may be considered medically necessary in children aged one (1) through seventeen (17) years of age:

  • Adenotonsillectomy; or
  • Uvulopharyngopalatoplasty (UPPP) in children with neuromuscular disorders who are deemed to be at high risk for persistent upper airway obstruction after adenotonsillectomy alone; or
  • Other surgical options available for patients not responding to usual treatment include:
    • craniofacial surgery; or
    • tracheostomy 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 aged one (1) through seventeen (17) years of age:

  • Uvulectomy; or
  • Laser-assisted uvuloplasty (LAUP); or
  • Somnoplasty or Coblation; or
  • Repose System; 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.

The safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

31600316014151241530421404214542820
42821428254282642830428314283542836
S2080

Hypoglossal Nerve Stimulators

Hypoglossal nerve stimulators may be considered medically necessary in children with Down syndrome and OSA when ALL the following criteria are met:

  • Age 10 to 17 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, un-desirable 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 retro palatal 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 criteria 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

6456864569645700466T0467T0468T

Diagnosis Codes

G47.33G47.411G47.419G47.421G47.429Q90.0Q90.1
Q90.2Q90.9

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