HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
Z-64-010
Topic:
Diagnosis and Treatment of Obstructive Sleep Apnea in Children
Section:
Miscellaneous
Effective Date:
September 17, 2018
Issued Date:
September 17, 2018
Last Revision Date:
September 2018
Annual Review:
September 2018
 
 

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.

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

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.

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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.

 

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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.

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Positive Airway Pressure (PAP)
CPAP in children aged one (1) through seventeen (17) years of age:

  • 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.

 

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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.

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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.

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Refer to Medical Policy E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME) for addtional information.

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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 in Children 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


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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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.