Obstructive sleep apnea (OSA) diagnosis 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 (PSG) either in a clinic/facility or at home.

OSA is characterized by:

• Fifteen (15) or more predominantly obstructive respiratory events (apneas, hypopneas, or RERAs) per hour of sleep (for PSG) or recording time (for at home PSG), regardless of the presence of associated symptoms or comorbidities; or 
• Five (5) or more predominantly obstructive respiratory events (obstructive and mixed apneas, hypopneas, or RERAs) per hour of sleep (for PSG) or recording time (for at home PSG) in an individual with at least ONE of the following:
  • Habitual snoring, breathing interruptions, or both noted by a bed partner or other observer; or 
    • Note: Socially disruptive snoring is not a disease, illness, or injury. 
  • Hypertension, mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or Type II Diabetes Mellitus (DM); or
  • Sleepiness, non-restorative sleep, fatigue, or insomnia symptoms; or 
  • Waking up with breath holding, gasping, or choking. 

OSA severity classification is based on two (2) measures:

• Apnea/hypopnea index (AHI) which includes the total number of apneas and hypopneas recorded during sleep, divided by the hours of sleep recorded; or
• Respiratory disturbance index (RDI) which includes the total number of apneas, hypopneas, and RERA during sleep, divided by the hours of sleep observed. 
• Severity classification: 
  • Mild OSA: RDI or AHI five (5) to 15 respiratory events per hour of sleep.
  • Moderate OSA: RDI or AHI 15 to 30 respiratory events per hour of sleep. 
  • Severe OSA: RDI or AHI greater than 30 respiratory events per hour of sleep.

Unattended/Unsupervised PSG Diagnostic Testing

A single unattended/unsupervised PSG test with a minimum of four (4) recording channels including oxygen saturation, respiratory movement, airflow, and EKG or heartrate or peripheral arterial tone (PAT), oximetry, heart rate and actigraphy may be considered medically necessary for/ ANY of the following codnitions:

• Adult individuals who are at high risk for OSA and have a controlled health condition; or
• Adult individuals who are at high risk for OSA and have no current evidence of a health condition that may alter ventilation or require alternative treatment; or
• A screening tool for adult individuals who are scheduled for bariatric surgery and have no evidence of a health condition that might alter ventilation or require alternative treatment; or
• Adults individuals requiring positive airway pressure (PAP) via continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) initiation or 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 individuals with moderate to severe OSA without significant comorbidities; or
• Adult individuals to monitor the response to non-CPAP treatments for OSA, including but not limited to:
  • Evaluating response to oral appliance treatment; or
  • Evaluating for surgical treatment/upper airway surgery; or
  • Evaluation after significant weight loss.
    • Note: After substantial weight loss (10 percent 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.  For example, 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.
    • 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.

Unattended/unsupervised PSGs performed in the individual’s home must be interpreted by a qualified physician or an active staff member of a sleep center or laboratory accredited by the AASM or The Joint Commission.

Unattended/unsupervised home PSGs are considered experimental/investigational in individuals under 18 years of age and are therefore non-covered, because the safety and /or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Unattended/unsupervised home PSG not meeting the above criteria is considered experimental/investigational and is therefore non-covered, because the safety and /or effectiveness of this service cannot be established by the available published peer-reviewed literature.

The performance of multiple nights of unattended/unsupervised PSGs are:

• Recognized as one (1) study; and
• Will be paid as one (1) service; and
• The date of service is reported as the date the study is complete.

Repeat Unattended/Unsupervised Home PSG

Repeat unattended/unsupervised sleep studies for adults (18 years of age or older) may be considered medically necessary with a minimum of three sensors as described above 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.

Facility/Laboratory Attended PSG

Supervised PSG with a minimum of seven (7) recording channels (including electroencephalography (EEG), electrooculogram (EOG), chin electromyography (EMG), electrocardiogram (ECG) or heart rate, airflow, respiratory effort, and oxygen saturation) performed in a sleep facility/laboratory may be considered medically necessary in individuals with a moderate or high pretest probability of OSA for the following indications:

• Pediatric individuals (17 years of age or younger); or
• Individual does not meet criteria for an unattended home sleep apnea test as outlined in this policy; or
• A previous home study failed to establish the diagnosis of OSA in an individual with a high pretest probability of OSA; or
• A previous home study was technically inadequate; or
• Failure of resolution of symptoms or recurrence of symptoms during treatment; or
• When testing is done to rule out other sleep disorders which may include but is not limited to:
  • Central sleep apnea; or
  • Narcolepsy; or
  • Parasomnias, injurious or potentially injurious; or
• Observed apneas during sleep and AT LEAST two (2) of the following:
  • Craniofacial or upper airway soft tissue abnormalities, including adenotonsillar hypertrophy; or
  • Excessive daytime sleepiness evidenced by:
    • Epworth Sleepiness Scale greater than 10; or
    • Inappropriate daytime napping; or
    • Sleepiness that interferes with daily activities and is not explained by other conditions; or
  • Gasping/Choking episodes with awakenings; or
  • Habitual snoring; or
  • Individual screening for bariatric surgery; or
  • Hypertension; or
  • Neuromuscular disease, including but not limited to:
    • Amyotrophic Lateral Sclerosis (ALS); or
    • Myotonic Dystrophy (MD); or
    • Parkinson’s Disease (PD); or
    • Spina Bifida (SB); or
  • Obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m²; 

AND

• The presence of ONE of the following comorbidities (disease process or sleep disorder) that might alter ventilation or decrease the accuracy of a home sleep apnea test, which may include, but not limited to:
  • Atrial fibrillation; or
  • Central sleep apnea; or
  • Cerebrovascular Attack/Accident (CVA) (stroke or transient ischemic attack [TIA]); or
  • Chronic opiod use; or
  • Circadian rhythm disorder; or
  • Coronary Artery Disease (CAD); or
  • Type II DM; or
  • Heart Failure; or
  • Insomnia; or
  • Parasomnias; or
  • Narcolepsy; or
  • Neuromuscular disease; or
  • Obesity hypoventilation syndrome; or
  • Periodic limb movement in sleep; or
  • Pulmonary disease, chronic; or
  • Restless Leg Syndrome; or
  • Significant tachycardia; or
• In individuals with sleep related breathing disorders requiring PAP via CPAP or BiPAP initiation and titration with the following proven option for titration:
  • Evaluation for the presence of OSA in individuals 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.
    • Note: After substantial weight loss (10 percent 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.  For example, 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.
    • 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.

Repeat Facility/Laboratory Attended Sleep Studies

A repeat supervised polysomnography performed in a sleep laboratory may be considered medically necessary for ANY of the following circumstances:

• To initiate and titrate continuous positive airway pressure (CPAP) in adult individuals with clinically significant OSA defined as those individuals who have (see next policy section below):
  • An AHI of at least 15 per hour; or
  • An AHI of at least five (5) per hour in an individual with excessive daytime sleepiness or hypertension; or
• 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.

Polysomnography or repeat polysomnography sleep studies that do not meet the above criteria for repeat studies are considered not medically necessary.

CPAP or BiPAP Initiation and Titration Related to PSG

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 not meeting the criteria as indicated in this policy is 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.

Multiple Sleep Latency Test (MSLT)/Maintenance of Wakefulness Test (MWT)

MSLT/MWT in the diagnosis of OSA is considered not medically necessary EXCEPT to exclude or confirm narcolepsy. 

MSLT/MWT not meeting the criteria as indicated in this policy is considered not medically necessary. 

Actigraphy 

Actigraphy may be considered medically necessary when used as a component of PSG in order to evaluate sleep disorders.  When used as a component of PSG actigraphy should not be reported separately.

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 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.

Surgical Treatment

The following surgical interventions may be considered medically necessary for the treatment of clinically significant OSA in adults who have failed an adequate trial of CPAP or failed an adequate trial of an oral appliance:

• Adenoidectomy; or
• Adenotonsillectomy; or
• Hyoid suspension; or
• Maxillofacial surgery, including mandibular-maxillary advancement (MMA); or
• Pataopharyngoplasty, including but not limited to:
  • Expansion sphincter pharyngoplasty; or
  • Lateral pharyngoplasty; or
  • Palatal advancement pharyngoplasty; or
  • Relocation pharyngoplasty; or
  • Uvulopalatal flap; or
  • Uvulopalatopharyngoplasty (UPPP); or
  • Uvulopalatopharyngoplasty; or
• Tongue modification, surgical; or
• Tonsillectomy; or
• Tracheostomy.

Surgical treatment of OSA not meeting the criteria as indicated in this policy is considered not medically necessary.

ALL interventions are considered not medically necessary for the treatment of snoring in the absence of documented OSA.

Due to of the likelihood of adverse effects, surgery should be limited to individuals who are unable to tolerate CPAP.

Experimental/Investigational Procedures

The following minimally invasive surgical procedures for treatment of OSA are considered experimental/investigational and, therefore, non-covered because the safety and effectiveness of these services cannot be established by the available published peer-reviewed literature:

• Atrial overdrive pacing: or
• Laser-assisted palatoplasty (LAUP) or radiofrequency volumetric tissue reduction of the palatal tissues: or
• Laser-assisted tonsillectomy or laser ablation of the tonsils (LAT): or
• 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: or
• Partial glossectomies: or
• Polypectomy: or
• Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues (e.g., Somnoplasty): or
• Septoplasty: or
• Tongue base suspension (e.g., Repose™ System): or
• Turbinectomy: or
• Uvulectomy: or
• All other minimally invasive surgical procedures not described above.

Hypoglossal Nerve Stimulators

Hypoglossal nerve stimulators may be considered medically necessary in adults with OSA when ALL of the following criteria are met:

• Age greater than or equal to 18 years; and
• AHI greater than or equal to 20 with less than 25 percent central apneas; and
• CPAP failure (residual AHI greater than 20 or failure to use CPAP greater than or equal to four (4) hours per night for five (5) or more nights per week) or inability to tolerate CPAP; and
• Body mass index less than or equal to 32 kg/m2; and
• Non-concentric retropalatal obstruction on Drug-Induced Sleep Endoscopy (DISE).

Hypoglossal nerve stimulators may be considered medically necessary in young adults with Down syndrome and OSA under ALL the following conditions:

• Age 18 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 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 retropalatal obstruction on DISE.

Use of hypoglossal nerve stimulators for OSA that does not meet the criteria as indicated in this policy is 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.