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:
Insomnia
Depression
Restless leg syndrome (to diagnosis or treat)
Circadian rhythm disorders
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:
An evaluation must be performed prior to the polysomnography that includes a thorough sleep history and a physical examination, which includes the respiratory, cardiovascular and neurologic systems; and
The diagnosis cannot be made through clinical evaluation of the signs and symptoms, or through use of less comprehensive diagnostic tests; and
The polysomnography results are used as a diagnostic test in individuals who present with any of the following:
Witnessed apneas, hypopneas, or respiratory effort related events while sleeping; or
Snoring associated with observed apneas and/or excessive daytime sleepiness; or
Unexplained hypertension or arrhythmia when sleep related complaints are present; or
Suspected narcolepsy (refer to MSLT under Additional Information); or
Sleep related behaviors that are violent or otherwise injurious (e.g., atypical or unusual parasomnias); or
Periodic limb movements during sleep in individuals who present with complaints of excessive daytime sleepiness associated with fragmented sleep; or
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:
Loud snoring with irregular respirations or apnea and co-morbid conditions associated with apnea (e.g., tonsil hypertrophy, obesity, neuromuscular disease, genetic syndromes, cranial facial abnormalities); or
Sleepwalking and night terrors associated with co-morbid conditions associated with sleep apnea; or
"Seizure" like events in sleep when a routine EEG has not detected the epileptic phenomena; or
Decreasing scholastic performance, sudden personality changes, enuresis (bedwetting) without other obvious cause, associated with hypersomnolence and co-morbid conditions associated with sleep apnea; or
Presence of systemic hypertension; or
Pulmonary hypertension; or
Marked sinus arrhythmia and bradycardia.
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:
Substantial weight gain or loss (to ascertain whether pressure adjustments are needed); or
Clinical response is insufficient or symptoms have returned; or
When symptoms return following surgical or dental treatments for obstructive sleep apnea.
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:
The MSLT is performed following a PSG performed on the preceding night; and
A full MSLT or a four-nap test with at least two onset REM periods is required for an accurate diagnosis; single nap studies are not sufficient for the diagnosis of narcolepsy.
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:
The technology must have final approval from the appropriate government regulatory bodies.
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
The technology must improve the net health outcome.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the investigational settings.
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.
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EFFECTIVE DATE |
6/10/2006 |
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