Note: Where attended NPSG is indicated, a split-night study NPSG is considered medically necessary, in which the final portion of the NPSG is used to titrate continuous positive airway pressure (CPAP), if the Apnea Hypopnea Index (AHI) is greater than 15 in first 2 hours of a diagnostic sleep study. An additional full-night CPAP titration NPSG is considered medically necessary only if the AHI is less than or equal to 15 during the first 2 hours of a diagnostic sleep study, or if the split-night study did not allow for the abolishment of the vast majority of obstructive respiratory events (see section I.B. Member lacks the mobility or dexterity to use portable monitoring equipment safely at home.Īetna considers attended full-channel nocturnal polysomnography (NPSG) (Type I device) performed in a healthcare facility medically necessary for members meet criteria for implantation of the Inspire System.Member has low pretest probability of obstructive sleep apnea (normal BMI (less than 30), normal airway (Mallampati score 1 or 2), no snoring, and normal neck circumference (less than 17 inches in men, and less than 16 inches in women)) or.Member has negative or technically inadequate portable monitoring results or.central sleep apnea or complex sleep apnea or.parasomnias that are unusual or atypical because of the individual’s age at onset, the time, duration or frequency of occurrence of the behavior including, but not limited to: nocturnal seizures, psychogenic dissociative states, REM sleep behavior disorder, sleep talking and/or confusional arousals,.periodic limb movement disorder (involuntary, jerking movements of the legs during sleep causing excessive daytime sleepiness (EDS) due to sleep fragmentation),.Member has one or more of the following comorbid sleep disorders: super obesity (BMI greater than 45, or pulmonary function studies show obesity hypoventilation syndrome (BMI greater than 35 plus arterial blood gas with PCO 2 greater than 45, or BMI greater than 35 plus inability to lie flat in bed)) or.pulmonary hypertension (mean pulmonary artery pressure > 25 mm Hg),. congestive heart failure (NYHA class III or IV or LVEF less than 45%),.stroke with residual respiratory effects,.neuromuscular disease (e.g., Parkinson’s disease, spina bifida, myotonic dystrophy, amyotrophic lateral sclerosis),.moderate to severe pulmonary disease (for example, COPD or asthma) (with nocturnal oxygen use or daytime hypercapnia with documented arterial blood gasses showing pO 2 less than 60 or pCO 2 greater than 45),.Member has at least one of the following comorbid medical conditions that degrade the accuracy of portable monitoring: Attended Full-Channel Nocturnal Polysomnography (NPSG)Īttended full-channel nocturnal polysomnography (NPSG) (Type I device) performed in a healthcare facility is considered medically necessary for diagnosis in members with symptoms suggestive of obstructive sleep apnea (see Appendix), when attended NPSG is used as part of a comprehensive sleep evaluation with adequate followup, and member has one or more of the following indications for attended NPSG:. This Clinical Policy Bulletin addresses diagnostic and treatment modalities and associated accessories and supplies for obstructive sleep apnea in adults.Īetna considers the following tests medically necessary for diagnosing obstructive sleep apnea (OSA) in adults aged 18 years and older when criteria are met: Number: 0004 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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