HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Z-64-017
Topic:
Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
Section:
Miscellaneous
Effective Date:
October 31, 2022
Issued Date:
October 31, 2022
Last Revision Date:
October 2022
Annual Review:
May 2022
 
 

Obstructive Sleep Apnea (OSA) in pediatric individuals 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, or cor pulmonale, particularly in severe cases

For the purposes of this policy the treatment of OSA may be considered medically necessary when ANY of the following conditions are met::

  • A pediatric individual is defined as one (1) through 17 years of age
  • Clinically significant OSA for pediatric individuals is defined as follows:
    • Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of at least five (5) per hour; or
    • AHI or RDI of at least 1.5 per hour with excessive daytime sleepiness, behavioral problems, or hyperactivity.
  • Attended polysomnography (PSG) performed on pediatric equipment is the diagnostic test of choice for the pediatric individual because it is the only technique shown to quantify the ventilatory and sleep abnormalities associated with sleep-disordered breathing.
Policy Position

Diagnostic Criteria

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

  • The caregiver reports EITHER:
    • Snoring, or
    • Labored, obstructive, or paradoxyl breathing; and
  • The caregiver has observed ONE OR MORE of the following: 
    • Aggressive behavior; or
    • Diaphoresis; or
    • Excessive daytime sleepiness; or
    • Hyperactivity; or
    • Morning headaches; or
    • Movement arousals; or
    • Neck hyperextension during sleep; or
    • Paradoxical rib cage motion during inspiration; or
    • Secondary enuresis; or
    • Slow growth; and
  • PSG reveals one (1) or more obstructive apneas or hypopneas per hour of sleep; 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 pediatric individual's findings are not better explained by another sleep disorder, medical disorder, neurological disorder, medication, or substance abuse.

Diagnostic Testing

Home/Unattended Sleep Studies
The following diagnostic studies for the diagnosis of OSA in pediatric individuals are considered experimental/investigational because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature, may include but are not limited to:

  • Unattended home PSG's; or
  • Unattended portable PSG's; or
  • Other unattended screening techniques including but not limited to the following:
    • Actigraphy; or
    • Audio taping and videotaping; or
    • Daytime nap PSG; or
    • Questionnaires (clinical assessment); or
    • Radiological evaluation; or
    • Multiple sleep latency testing (MSLT)/Maintenance of wakefulness test (MWT).

95800

95801

95805

95806

G0398

G0399

G0400




Facility/Laboratory Attended PSG

PSG
Attended PSG for pediatric individuals meeting ANY of the following criteria may be considered medically necessary:

  • The caregiver has observed ONE OR MORE of the following: 
    • Aggressive behavior; or
    • Diaphoresis; or
    • Excessive daytime sleepiness; or
    • Failure to thrive; or
    • Hyperactivity; or
    • Morning headaches; or
    • Movement arousals; or
    • Neck hyperextension during sleep; or
    • Paradoxical rib cage motion during inspiration; or
    • Secondary enuresis.

AND one or more of the following:

  • Differentiation of benign or primary snoring from pathological snoring; or
  • Evaluation of:
    • Cor pulmonale; or
    • Disturbed sleep patterns; or
    • Excessive daytime sleepiness; or
    • Failure to thrive; or
    • Polycythemia unexplained by other factors or conditions; or
  • When clinical exam is not sufficient to determine that surgery is indicated; or
  • Determination of need for intensive postoperative monitoring following adenotonsillectomy or other pharyngeal surgery; or
  • Known history of OSA exhibiting persistent snoring or other symptoms of sleep disordered breathing despite therapy; or
  • Titration of continuous positive airway pressure (CPAP) levels.

PSG may be considered medically necessary when evaluating individuals with parasomnias when there is a history of sleep related injurious or potentialy injurious disruptive behaviors.

PSG in pediatric individuals not meeting the criteria as indicated in this policy is considered not medically necessary for ANY of the following:

  • Routine evaluation of adenotonsillar hypertrophy alone without other clinical signs or symptoms suggestive of obstructive sleep disordered breathing; or 
  • Routine follow-up of post-adenotonsillectomy with resolved symptoms.

Repeat PSG
Repeat PSG in pediatric individuals may be considered medically necessary when ANY of the following are met:

  • Initial PSG is inadequate or non-diagnostic and the accompanying caregiver reports that the pediatric individual's sleep and breathing patterns during the testing were not representative of their sleep at home; or
  • A pediatric individual 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 pediatric individual's growth pattern or the presence of recurrent symptoms while on CPAP; or
  • Significant weight loss has been achieved and repeat testing may be indicated to determine the need for continued therapy.

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.

Repeat PSG in pediatric individuals not meeting the criteria indicated in this policy is considered not medically necessary.

94772

95782

95783

95807

95808

95810

95811

 




PSG/RLS Criteria:

PSG may be considered medically necessary for the diagnosis of periodic limb movement disorder when ALL the following are criteria met:

  • A complaint of repetitive limb movement during sleep by the individual or an observer; and
  • No other concurrent sleep disorder; and
  • At least ONE of the following is present:
    • Frequent awakenings; or
    • Fragmented sleep; or
    • Difficulty maintaining sleep; or
    • Excessive daytime sleepiness.

PSG not meeting the criteria as indicated in the policy is considered not medically necessary.

95782

95783

95808

95810

95811

 

 




Multiple Sleep Latency Testing (MSLT)
After OSA has been ruled out by PSG, MSLT may be considered medically necessary in pediatric individuals for ANY of the following medical conditions:

  • Narcolepsy; or
  • Suspected idiopathic hypersomnia; or
  • When performed for ANY of the following: 
    • The first test was invalid or uninterpretable; or
    • The response to treatment needs to be determined; or
    • The pediatric individual is suspected of having more than one (1) sleep disorder (e.g., diagnosis of OSA and continues to have excessive daytime sleepiness despite treatment); or
    • The most recent prior MSLT test was conducted two (2) or more years ago.

MSLT not meeting the criteria as indicated in this policy is considered not medically necessary for EITHER of the following:

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

95805

 

 

 

 

 

 




Actigraphy 

Actigraphy in conjunction with PSG may be considered medically necessary to evaluate sleep disorders for individuals 17 years or younger.

Actigraphy used as a sole technique to record and analyze body movement to evaluate sleep disorders not meeting the criteria as indicated in this policy is considered not medically necessary.

95803

 

 

 

 

 

 




Positive Airway Pressure (PAP)
CPAP in pediatric individuals 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 pediatric individuals 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 durable medical equipment (DME).

CPAP for pediatric individuals not meeting the criteria as indicated in this policy is considered not medically necessary.

E0601

E0618

E0619

 

 

 

 




Intra-oral Appliances

Intra-oral appliances for the treatment of OSA in pediatric individuals with craniofacial anomalies may be considered medically necessary.

Intra-oral appliances for the treatment of OSA in pediatric individuals with craniofacial anomalies not meeting the criteria as indicated in this policy is considered not medically necessary.

Payment may be made for only one (1) appliance. Additional appliances are considered not medically necessary. Replacement of the appliance is covered in case of loss, irreparable damage, or wear when necessary due to a change in the individual's condition. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

E0485

E0486

 

 

 

 

 




Hypoglossal Nerve Stimulation

Hypoglossal nerve stimulation may be considered medically necessary in adolescents or young adults with Down syndrome and OSA under the ANY of the following conditions:

  • Age 10 to 21 years; and
  • AHI greater than 10 and less than 50 with less than 25 percent central apneas after prior adenotonsillectomy; and
  • Have EITHER:
    • A 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 greater than or equal to the 95th percentile for age; and
  • Non-concentric retropalatal obstruction on drug-induced sleep endoscopy (DISE).

Hypoglossal nerve stimulation for the treatment of OSA not meeting the criteria as indicated in this policy is considered not medically necessary.

64582

64583

64584

 

   

 




Surgical Treatment
The following surgical interventions to treat clinically significant OSA in pediatric individuals may be considered medically necessary for ANY of the following:

  • Adenoidectomy; or
  • Adenotonsillectomy; or
  • Tonsillectomy; or
  • Uvulopharyngopalatoplasty (UPPP) in pediatric individual's 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 pediatric individual's not responding to usual treatment include:
    • Craniofacial surgery; or
    • Tracheostomy in severe cases.

The following surgical interventions are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature may include but is not limited to:

  • Laser-assisted palatoplasty or radiofrequency volumetric tissue reduction of the palatal tissues; or
  • Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues; or
  • Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent, and the implantation of palatal implants; or
  • Tongue base suspension; or
  • All other minimally invasive surgical procedures not described above.

31600

31601

41512

41530

42140

42145

42820

42821

42825

42826

42830

42831

42835

42836

S2080

 

 

 

 

 

 




Related Policies

Refer to Medical Policy Z-8, Diagnosis and Treatment of Obstructive Sleep Apnea in Adults, for additional information.


Professional Statements and Societal Positions Guidelines

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 [individuals] are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.

 

American Academy of Pediatrics (AAP) - 2012

The American Academy of Pediatrics published guidelines on the diagnosis and management of uncomplicated childhood OSA associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy [pediatric individual] treated in the primary care setting, which updated the AAP's 2002 guidelines. AAP recommended that all [pediatric individuals] or adolescents be screened for snoring, and PSG is performed in [pediatric individuals] or adolescents with snoring and symptoms or signs of OSA as listed in the guideline. If PSG is not available, an alternative diagnostic test or referral to a specialist may be considered (option). The estimated prevalence rates of OSA in [pediatric individuals] ranged from 1.2% to 5.7%. Adenotonsillectomy was recommended as the first-line treatment for patients with adenotonsillar hypertrophy, and patients should be reassessed clinically postoperatively to determine whether additional treatment is required. High-risk patients should be reevaluated with an objective test or referred to a sleep specialist. CPAP was recommended if adenotonsillectomy was not performed or if OSA persisted postoperatively. Weight loss was recommended in addition to other therapy in patients who are overweight or obese, and intranasal corticosteroids are an option for [pediatric individuals] with mild OSA in whom adenotonsillectomy is contraindicated or for mild postoperative OSA.

 

American Academy of Sleep Medicine (AASM)

Oral Appliance Therapy – 2015

The AASM along with the American Academy of Dental Sleep Medicine (AADSM) engaged a seven member task force for the treatment of OSA and snoring with oral appliance therapy developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations.

 

Recommendations:

  • We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for [individuals] fitted with oral appliances.

 

Use of Actigraphy in Adult and Pediatric [Individuals] – 2018

The following AASM recommendations are intended as a guide for clinicians using actigraphy in evaluating [individuals] with sleep disorders and circadian rhythm sleep-wake disorders, and only apply to the use of FDA-approved devices. Each recommendation statement is assigned a strength (“Strong” or “Conditional”). A “Strong” recommendation (ie, “We recommend…”) is one that clinicians should follow under most circumstances. A “Conditional” recommendation (ie, “We suggest…”) reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all [individuals]. The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options, and resources.

  • Suggest clinicians use actigraphy in the assessment of pediatric [individuals] with insomnia disorder.
  • Suggest clinicians use actigraphy in the assessment of adult [individuals] with circadian rhythm sleep-wake disorder. (Conditional) 4. We suggest that clinicians use actigraphy in the assessment of pediatric [individuals] with circadian rhythm sleep-wake disorder.
  • Suggest clinicians use actigraphy to monitor total sleep time prior to testing with the Multiple Sleep Latency Test in adult and pediatric [individuals] with suspected central disorders of hypersomnolence.
  • Recommend clinicians not use actigraphy in place of electromyography for the diagnosis of periodic limb movement disorder in adult and pediatric [individuals].

 

Treatment of OSA with PAP Therapy – 2019

Based on expert consensus from the AASM, the following good practice statements and their implementation is necessary for appropriate and effective management of [individuals] with OSA treated with positive airway pressure:

  • Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing.
  • Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA.


Covered diagnosis codes for procedure code E0601

G47.33

 

 

 

 

 

 

Covered diagnosis codes for procedure codes 95803, 95805

G47.411

G47.419

G47.421

G47.429

 

 

 


Covered diagnosis codes for procedure codes
64582, 64583, 64584

G47.33

Q90.0

Q90.1

Q90.2

Q90.9

 

 

 


Non-Covered diagnosis code for procedure codes
41512, 41530, 42140, 42145, 95800, 95801, 95803, 95805, 95806, 95807, G0398, G0399, G0400, and S2080 are considered experimental/investigational when reported with Obstructive Sleep Apnea.

G47.33

 

 

 

 

 

 



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 pediatric individuals 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



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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.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





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.