BlueCross BlueShield of Tennessee Medical Policy Manual

Sleep Disorder Studies

DESCRIPTION

Sleep Apnea Syndrome (SAS)

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 individuals 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. If there is a high suspicion of sleep apnea syndrome after evaluating an individual, a sleep study is indicated to establish a diagnosis.

Polysomnography

Currently, polysomnography (PSG), which requires an overnight stay in a sleep laboratory, is the optimum test for diagnosing sleep apnea. It includes evaluation of sleep staging, airflow and ventilatory effort, arterial oxygen saturation, electrocardiogram (single lead), body position, and periodic limb movements (i.e., anterior tibialis EMG to assess sleep-associated leg movements). Determined from the collective data are total sleep time, sleep latency, arousals after sleep onset, time spent in nREM and REM sleep, central and obstructive sleep apneas, and the severity of SAS in terms of the apneas and/or hypopneas per hour. Only one polysomnogram is needed to confirm a diagnosis of SAS. A second polysomnogram may be required to adjust the nasal CPAP device. It is imperative that a sleep study be interpreted by someone with expertise in sleep disorders since an accurate diagnosis is crucial to avoid undertreatment or overtreatment of individuals. Treatment may consist of: modification of behavioral factors (i.e., weight loss, avoidance of alcohol and sedatives before sleep, avoidance of supine sleep position); nasal CPAP; oral/dental devices; or surgical procedures (uvulopalatopharyngoplasty [UPPP], nasal surgery, tonsillectomy, maxillofacial surgery, tracheostomy).

Sleep staging requires a 1-4 lead electroencephalogram (EEG) to monitor stages of sleep, electro-oculogram (EOG) to monitor eye movements and REM sleep, and a submental electromyogram (EMG).

Multiple Sleep Latency Testing (MSLT)

A multiple sleep latency test involves repeated measurement of sleep latency, which is the time to the onset of sleep. The test is performed in the daytime under standardized and controlled conditions following quantified nocturnal sleep. Usually two to six tests are performed, one testing every two hours, to measure daytime sleep tendency. A mean latency of five minutes or less indicates severe excessive sleepiness.

POLICY

A supervised polysomnography (PSG) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

A repeat supervised polysomnography (PSG) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Multiple sleep latency testing (MSLT) to exclude or confirm narcolepsy is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Multiple sleep latency testing (MSLT) in the diagnosis any other sleep related condition is considered not medically necessary.

Polysomnography as a diagnostic test for other conditions/diseases, including, but not limited to, the following is considered investigational:

Portable polysomnography ("In-home" sleep studies) is considered investigational.

See also: Actigraphy for Sleep Disorders

MEDICAL APPROPRIATENESS

Polysomnography Criteria

Adult Indications

Polysomnography is considered medically appropriate if all of the following criteria are met:

Pediatric Indications

Adult criteria for sleep apnea syndrome (respiratory disturbance index [RDI] and/or apneic events per hour) do not identify the majority of children with serious upper airway obstruction during sleep. Symptoms in children that may be indicative of sleep apnea syndrome include:

A repeat supervised polysomnography is considered medically appropriate to evaluate treatment efficacy during nasal continuous positive airway pressure titration for individuals that meet any of the following criteria:

Multiple Sleep Latency Testing (MSLT)

Multiple sleep latency testing (MSLT) is considered medically appropriate to exclude or confirm narcolepsy if all of the following conditions are met:

ADDITIONAL INFORMATION

Only one polysomnogram is needed to confirm a diagnosis of obstructive sleep apnea syndrome (OSAS). A second polysomnogram may be required to adjust the CPAP device. Additional polysomnograms may be necessary for evaluating treatment response and making subsequent treatment management decisions. More than three polysomnograms in a 12-month period should undergo utilization review.

A polysomnogram that is diagnostic for sleep apnea syndrome in adults is one with a RDI greater than five. This number represents the number of apneas and hypopneas per hour of sleep. For example, 60 apneic periods during an eight-hour study results in an RDI of 7.5.

Sleep studies must be performed in a place of service certified as required by applicable state and federal regulations, and accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and/or accredited by the American Osteopathic Association (AOA) and/or accredited by the American Academy of Sleep Medicine. The evaluating physician and staff are required to have specialized training that meets the standards set forth by the American Academy of Sleep Medicine.

No controlled studies were found in the published literature that validate the use of polysomnography as a diagnostic test for insomnia, depression, restless leg syndrome or to diagnosis circadian rhythm disorders. There is insufficient evidence supporting the use of portable polysomnography for "in-home" sleep studies.

Polysomnography as a diagnostic test for insomnia, depression, restless leg syndrome, or to diagnosis circadian rhythm disorders, and portable polysomnography ("in-home" sleep studies) to diagnosis or for medical management of sleep apnea syndrome does not meet the following technology evaluation criteria:

SOURCES

American Academy of Pediatrics. (2002). Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Retrieved January 6, 2006 from http://www.aap.org/policy/re0118.html.

American Academy of Sleep Medicine. (2001). Professional standards: Polysomnographic technologist description. Retrieved January 13, 2006 from http://www.aasmnet.org/PDF/PolysomnographicTechnologists.pdf.

American Academy of Sleep Medicine. (2001). Professional standards: Polysomnographic technician description. Retrieved January 13, 2006 from http://www.aasmnet.org/PDF/PSGTechnician.pdf.

American Academy of Sleep Medicine. (2005, June). Standards for accreditation of sleep disorders centers. Retrieved January 13, 2006 from http://www.aasmnet.org/PDF/CenterStandards.pdf.

American Academy of Sleep Medicine. (2005, June). Standards for accreditation of laboratories for sleep related breathing disorders. Retrieved January 13, 2006 from http://www.aasmnet.org/PDF/LaboratoryStandards.pdf.

American Sleep Disorders Association. (1999). Indications for the clinical use of unattended portable recording for the diagnosis of sleep-related breathing disorders. ASDA News, 6 (1), 19-22.

American Thoracic Society. (1999, February). Cardiorespiratory sleep studies in children: Establishment of normative data and polysomnographic predictors of morbidity. American Journal of Respiratory and Critical Care Medicine, 160 (4), 1381-1387.

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2005). Diagnosis and medical management of obstructive sleep apnea syndrome (2.01.18). Retrieved November 11, 2005 from BlueWeb.

Chesson, A. L., Jr., Berry, R. B., & Pack, A. (2003). Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. SLEEP, 26 (7), 907-913.

Complete Guide to Medicare Coverage Issues [Computer software]. (2005, November). Sleep disorder clinics (Section 70, p. 4-191, 4-192). St. Anthony Publishing.

Kushida, C. A., Littner, M. R., Morgenthaler, T., Alessi, C. A., Bailey, D., Coleman, J., Jr., et al. (2005). Practice parameters for the indications for polysomnography and related procedures: An update for 2005. SLEEP, 28 (4), 499-521.

Littner, M. R., Kushida, C., Wise, M., Davila, D. G., Morgenthaler, T., Lee-Chiong, T., et al. (2005, January). An American Academy of Sleep Medicine Report. Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. SLEEP, 28 (1), 113-121.

National Guideline Clearinghouse. (2003). Practice parameters for using polysomnography to evaluate insomnia: An update. Retrieved January 10, 2006 from National Guideline Clearinghouse database.

National Guideline Clearinghouse. (2005). Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Retrieved November 11, from National Guideline Clearinghouse database.

National Guideline Clearinghouse. (2005). Guideline: Diagnosis and treatment of obstructive sleep apnea. Retrieved November 10, from National Guideline Clearinghouse database.

EFFECTIVE DATE

6/10/2006

 

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.

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