BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy on Sleep Apnea

PURPOSE

To establish a basis for determining appropriate testing and treatment of individuals with sleep apnea.

DESCRIPTION

Sleep apnea syndrome is a breathing disorder characterized by the cessation of breathing for at least ten seconds, which occurs repetitively throughout the night and is accompanied by hypoxia and hypercapnia. Apnea may occur as a result of failure of respiratory drive (central apnea), obstruction of the upper airway (obstructive apnea), or a mixed pattern (mixed apnea) during sleep. The initial evaluation of anyone suspected of having sleep apnea syndrome should include a thorough medical and sleep history (including family or bed partner observations), and a physical examination including laboratory serologic testing, and possibly a detailed sleep log and/or psychological testing.

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness for testing and treatment of sleep apnea.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

DIAGNOSTICS:

• Actigraphy for Sleep Disorders

• Home Pulse Oximetry

• Infant Home Apnea Monitoring

• Sleep Disorder Studies

THERAPEUTICS:

• Laser Assisted Uvulopalatoplasty (LAUP)

• Oral Appliances for Management of Mild to Moderate Obstructive Sleep Apnea (OSA)

• Orthognathic Surgery

• Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring

• Palatopharyngoplasty (PPP)

• Radiofrequency Tissue Volume Reduction for the Treatment of Upper Airway Obstruction

• Uvulopalatopharyngoplasty (UPPP)

ORIGINAL EFFECTIVE DATE:  12/30/1999  

MOST RECENT REVIEW DATE:  6/18/2008

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.