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::
Diagnostic Criteria
Diagnosis of OSA in pediatric individuals is made when ALL of the following criteria are met:
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:
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:
AND one or more of the following:
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:
Repeat PSG
Repeat PSG in pediatric individuals may be considered medically necessary when ANY of the following are met:
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:
PSG not meeting the criteria as indicated in the policy is considered not medically necessary.
95782 |
95783 |
95808 |
95810 |
95811 |
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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:
MSLT not meeting the criteria as indicated in this policy is considered not medically necessary for EITHER of the following:
95805 |
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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 |
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Positive Airway Pressure (PAP)
CPAP in pediatric individuals may be considered medically necessary in ANY of the following situations:
When the above criteria are met:
CPAP for pediatric individuals not meeting the criteria as indicated in this policy is considered not medically necessary.
E0601 |
E0618 |
E0619 |
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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 |
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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:
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 |
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Surgical Treatment
The following surgical interventions to treat clinically significant OSA in pediatric individuals may be considered medically necessary for ANY of the following:
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:
31600 |
31601 |
41512 |
41530 |
42140 |
42145 |
42820 |
42821 |
42825 |
42826 |
42830 |
42831 |
42835 |
42836 |
S2080 |
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Refer to Medical Policy Z-8, Diagnosis and Treatment of Obstructive Sleep Apnea in Adults, for additional information.
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:
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.
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:
Covered diagnosis codes for procedure code E0601
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Covered diagnosis codes for procedure codes 95803, 95805
G47.411 |
G47.419 |
G47.421 |
G47.429 |
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Covered diagnosis codes for procedure codes 64582, 64583, 64584
G47.33 |
Q90.0 |
Q90.1 |
Q90.2 |
Q90.9 |
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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 |
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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.
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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:
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.
