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 a patient 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 ten (10) second cessation of respiration associated with ongoing ventilatory effort.  Hypopnea is defined as an abnormal respiratory event lasting at least ten (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 AHI greater 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 patients 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 patients 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/m²; or

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

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 patients 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 and a comorbid medical condition or comorbid sleep disorder:
  • Excessive daytime sleepiness evidenced by an Epworth Sleepiness Scale greater than ten (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 to 30 kg/m²; or
  • 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 patients 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 patient, 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 ten (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:

• Patients 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 patients 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.

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 of two (2) hours of sleep. Alternatively, an AHI of 20 to 39 events per hour of sleep is documented during a minimum of two (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 than three (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 above are 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.

REPEAT SLEEP STUDIES

Repeat OCST/PM Unattended Sleep Study 

Repeated OCST/PM Unattended sleep studies may be considered medically necessary in adult patients 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 necessary for ANY ONE of the following circumstances:

• To initiate and titrate continuous positive airway pressure (CPAP) in adult patients 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.

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 maintenance of wakefulness test is considered experimental/investigational for ALL indications 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 sole technique 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.

MEDICAL TREATMENT

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.

Behavior Modification 

Behavioral treatment options include weight loss, ideally to a BMI of 25 kg/m² or 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 patients. 

Successful dietary weight loss may improve the AHI in obese patients 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 E-20 Devices Used for the Treatment of Obstructive Sleep Apnea in Adults for additional information.

Intra-Oral Appliances

Refer to medical policy E-20 Devices Used for the Treatment of Obstructive Sleep Apnea in Adults for additional information.

SURGICAL TREATMENT

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

Note: A tonsillectomy is considered an integral component of UPPP and is not separately reimbursed.

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 patients 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). 

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 patients who have:

• AHI or RDI greater than or equal to fifteen (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.

Implantable hypoglossal nerve stimulators (64568, 0466T, 0467T and 0468T) are considered experimental/investigational and, therefore, non-covered for the treatment of adult OSA due to insufficient evidence in the peer-reviewed published medical literature regarding its effectiveness and safety.

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 patients who are unable to tolerate CPAP. Minimally invasive surgical procedures have limited efficacy in patients with mild to moderate OSA and have not been shown to improve AHI or excessive daytime sleepiness in adult patients with moderate to severe OSA. These are considered experimental/investigational and, therefore, non-covered. 

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.