BlueCross BlueShield of Tennessee Medical Policy Manual

Actigraphy

DESCRIPTION

Actigraphy refers to the assessment of activity patterns by devices typically placed on the wrist or ankle that record body movement, which is interpreted by computer algorithms as periods of sleep (absence of activity) and wake (activity).

Actigraphy devices are typically worn continuously for at least 24 hours. Activity is usually recorded for a period of three days to two weeks. The activity monitors may be placed on the ankle for the assessment of restless legs syndrome, or on the trunk to record movement in infants. Proprietary software is then used to calculate periods of sleep based on the absence of detectable movement, along with movement-related level of activity and periods of wake. In addition to providing graphic depiction of the activity pattern, device-specific software may analyze and report a variety of sleep parameters including sleep onset, sleep offset, sleep latency, total sleep duration, and wake after sleep onset. For clinical applications, actigraphy is being evaluated as a measure of sleep-wake cycles in sleep disorders, including insomnia and circadian rhythm sleep disorders

Note:  This policy only addresses actigraphy as a stand-alone test.  When performed as a component of portable home sleep testing, actigraphy should not be reported separately.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Evidence demonstrating that actigraphy provides a reliable measure of sleep efficiency is lacking. The evidence is insufficient to determine the effects of the technology on health outcomes.

SOURCES 

American Academy of Sleep Medicine. (2017, February). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine practice guideline. Retrieved September 7, 2017 from http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf.

American Academy of Sleep Medicine. (2018, July). Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: An American Academy of Sleep Medicine Clinical Practice. Retrieved August 14, 2018 from http://jcsm.aasm.org/ViewAbstract.aspx?pid=31329.

Blake, M.J., Sheeber, L.B., Youssef, G.J., Raniti, M.B., & Allen, N.B. (2017). Systematic review and meta-analysis of adolescent cognitive-behavioral sleep interventions. Clinical Child Family Psychology Review, 20 (3), 227-249. (Level 1 evidence)

BlueCross BlueShield Association. Evidence Positioning System. (7:2019). Actigraphy (2.01.73). Retrieved August 29, 2019 from https://www.evidencepositioningsystem.com/. (18 articles and/or guidelines reviewed)

CMS.gov: Center for Medicare & Medicaid Services. Palmetto GBA. (2019, January). Polysomnography (LCD L36593). Retrieved August 29, 2019 from www.cms.gov.

De Crescenzo, F., Licchelli, S., Ciabattini, M., Menghini, D., Armando, M., Alfieri, P, et al. (2016). The use of actigraphy in the monitoring of sleep and activity in ADHD: a meta-analysis. Sleep Medicine Reviews, 26, 9-20. Abstract retrieved August 29, 2019 from PubMed database.

Louter, M., Arends, J., Bloem, B., & Overeem, S. (2014). Actigraphy as a diagnostic aid for REM sleep behavior disorder in Parkinson’s disease. BioMed Central Neurology, 14 (76), 1-8. (Level 4 evidence)

U.S. Food and Drug Administration. (1985). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K854030. Retrieved April 16, 2014 from, http://www.accessdata.fda.gov. 

U.S. Food and Drug Administration. (2004). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K040554. Retrieved September 26, 2016 from http://www.accessdata.fda.gov.

ORIGINAL EFFECTIVE DATE:  1/14/2006

MOST RECENT REVIEW DATE:  10/10/2019    

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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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