MEDICAL POLICY Sleep Study Testing

Transcription

1 POLICY: PG0207 ORIGINAL EFFECTIVE: 02/01/09 LAST REVIEW: 10/22/15 MEDICAL POLICY Sleep Study Testing GUIDELINES This plicy des nt certify benefits r authrizatin f benefits, which is designated by each individual plicyhlder cntract. Paramunt applies cding edits t all medical claims thrugh cding lgic sftware t evaluate the accuracy and adherence t accepted natinal standards. This guideline is slely fr explaining crrect prcedure reprting and des nt imply cverage and reimbursement. DESCRIPTION A sleep study is a test that may be used t assist in the diagnsis f sleep disrders, such as sleep apnea, narclepsy r ther night time behavirs. It can recrd a range f bdily functins during sleep, such as: measurement f breathing, respiratry effrt, xygen saturatin levels, heart mnitring, eye mvement and heart, brain and muscle activity. A sleep study may be perfrmed in a sleep facility/labratry r in the hme. Hme/Prtable Mnitr Sleep Testing is a sleep study perfrmed in the hme that utilizes prtable mnitring (PM) devices that are designed t be used by a patient withut supervisin f a sleep technlgist. The system usually cnsists f a recrding device and related accessries. PM devices measure fewer parameters than a labratry based sleep study and are therefre nt recmmended fr assessment f sleep disrder in the pediatric ppulatin. Plysmngram (PSG) is a sleep study that is perfrmed in a facility/labratry setting and requires an vernight stay. PSG is designed t capture multiple sensry channels including brain waves, heartbeat, bld pressure and breathing patterns as a patient sleeps. It can als recrd eye and leg mvements and muscle tensin which can be useful in diagnsing parasmnias. A PSG perfrmed at a facility will recrd a minimum f 12 channels which invlves at least 22 wire attachments t the patient. Sensrs that send electrical signals t a cmputer are placed n the head, face, chest and legs. This test is attended by a technlgist and the results are evaluated by a qualified physician. A PSG may be perfrmed in cnjunctin with a psitive airway pressure (PAP) machine t determine the titratin f xygen flw. Psitive Airway Pressure (PAP) titratin study is used t set the right level f PAP which can be administered as cntinuus psitive airway pressure (CPAP) r bilevel psitive airway pressure (BPAP) nce patient tlerance and ptimal levels are determined by a sleep technlgist. PAP titratin may be perfrmed in cnjunctin with a PSG as part f a secnd r split night study if the diagnsis f mderate r severe OSA can be made within the first tw hurs f recrded sleep and at least three hurs f PAP titratin, including the ability f PAP t eliminate respiratry events during bth rapid eye mvement (REM) sleep and nn REM sleep, is demnstrated. Facility based, daytime, abbreviated, cardirespiratry sleep studies (PAP NAP testing) uses a therapeutic framewrk that includes mask and pressure desensitizatin, emtin fcused therapy t vercme aversive emtinal reactins, mental imagery t divert patient attentin frm mask r pressure sensatins and physilgical expsure t PAP therapy during a 100 minute nap perid which is purprted t enhance PAP therapy adherence. Multiple Sleep Latency Test (MSLT) is a facility based study that is used t measure levels f daytime sleepiness. During a rutine MSLT, a patient is given five nap trials that are separated by tw hur intervals: each trial cnsists f a twenty-minute sessin in which the patient attempts t fall asleep. Onset f sleep and rapid eye mvement, alng with heartbeat and chin mvements are recrded. The test is typically perfrmed n the night fllwing a PSG (where at least six hurs f sleep were achieved) in rder t rule ut ther sleep disrders as a cause f excessive daytime sleepiness. The results f the study are primarily used t cnfirm the suspected diagnsis f narclepsy. Maintenance f Wakefulness Test (MWT) is a facility based study that is used t measure the ability t stay awake and alert. The prcedure prtcl is similar t that f the MSLT, with the exceptin that a patient is given fur nap trials, each trial cnsisting f a frty minute sessin in which the patient attempts t fall asleep. The test is rutinely perfrmed the day after a ncturnal PSG and evaluates the ability t stay awake fr a defined perid f time. Results may be used t determine the efficacy f therapy fr sleep disturbance disrders (such as narclepsy) r t determine if the inability t stay awake is a public r persnal safety cncern.

2 - 2 - POLICY Adult hme sleep testing (95800, 95801, 95806, G0398, G0399, G0400) and adult facility sleep testing (95808, 95810, 95811) des nt require prir authrizatin. Pediatric hme sleep testing (95800, 95801, 95806, G0398, G0399, G0400) is nn-cvered. Pediatric facility sleep testing (95782, 95783, 95808, 95810, 95811) des nt require prir authrizatin. Wakefulness testing (MWT) (95805) and multiple sleep latency testing (MSLT) d nt require prir authrizatin. Prescreening devices t predict pretest prbability f OSA (e.g., SleepStrip, acustic pharyngmetry) and abbreviated cardirespiratry sleep study (e.g., PAP-Nap) (95807) are nn-cvered. Fr actigraphy testing (95803) refer t PG0198 Actigraphy and Accelermetry fr cverage determinatin. HMO, PPO, Individual Marketplace, Elite, Advantage Cverage f, testing fr, and the treatment f bstructive sleep apnea and ther sleep disrders is subject t the terms, cnditins and limitatins as described in the applicable benefit plan s schedule f cpayments. Please refer t the applicable benefit plan dcument and schedules t determine benefit availability and the terms, cnditins and limitatins f cverage particularly arund cverage fr testing required fr emplyment, insurance cverage, r gvernment license purpses. Even when there is n exclusin in the benefit plan fr such cverage, Paramunt cnsiders screening fr r the evaluatin f bstructive sleep apnea r ther sleep disrder t be nt medically necessary when required fr emplyment, insurance r gvernment license purpses in the absence f symptms suggestive f bstructive sleep apnea r ther sleep disrder. Adult Hme Sleep Study (95800, 95801, 95806, G0398, G0399, G0400) A. Paramunt cvers a sleep study as medically necessary fr the diagnsis f suspected bstructive sleep apnea (OSA) in an adult (age 18 r lder) when BOTH f the fllwing criteria are met: evidence f daytime sleepiness (e.g., excessive sleepiness nt explained by ther factrs, nn-refreshing sleep, sleep fragmentatin) ANY f the fllwing additinal symptms r risk factrs f OSA: witnessed apneas gasping r chking at night disruptive snring increased neck circumference (i.e., > 17 inches in men, > 16 inches in wmen) besity (i.e., bdy mass index 30) B. Paramunt cvers a hme/prtable sleep study* as medically necessary fr the diagnsis f bstructive sleep apnea (OSA) in an adult (age 18 r lder) when ALL f the fllwing criteria are met: medical necessity criteria fr a sleep study fr suspected OSA as utlined abve have been met absence f significant cmrbid cnditin that wuld be expected t degrade the accuracy f a hme/prtable study, such as any f the fllwing: mderate t severe pulmnary disease, such as chrnic bstructive pulmnary disease (COPD) mderate t severe neurmuscular/neurdegenerative disrder causing restrictive lung diseases (e.g., kyphsclisis, myasthenia gravis, amytrpic lateral sclersis (ALS), pli, Plymysitis, Guillian Barre syndrme) cngestive heart failure Class III r IV besity hypventilatin syndrme, previusly dcumented pulmnary hypertensin n sleep disrder ther than OSA is suspected (e.g., central sleep apnea, peridic limb mvement disrder, parasmnias, narclepsy, REM behavir sleep disrder) *Nte: A hme/prtable study is cnsidered t be ne study, whether perfrmed during a single night r during tw r mre cnsecutive nights. C. Paramunt cvers a hme/prtable sleep study when the diagnsis f OSA has been established in an adult (age 18 r lder) when ALL f the fllwing criteria are met: testing is t be perfrmed fr ANY f the fllwing:

3 - 3 - cnfirmatin f therapeutic benefit fllwing final adjustment f a mandibular repsitining appliance (MRA) assessment f results fllwing surgical treatment fr OSA clinical respnse is insufficient r symptms return despite a gd initial respnse t a mandibular repsitining appliance n significant xygen desaturatin* during diagnstic sleep study absence f cmrbid sleep disrder r significant cmrbid medical cnditin, as described abve, that wuld be expected t degrade the accuracy f a hme/prtable study D. Paramunt cvers hme titratin using aut-titrating PAP (APAP) t determine a fixed CPAP pressure fr nging treatment when ALL f the fllwing criteria are met: individual meets the criteria fr PAP (detailed in PAP sectin belw) individual des nt have a cmrbid cnditin that wuld be expected t degrade the accuracy f auttitratin, such as any f the fllwing: cngestive heart failure Class III r IV significant lung disease [e.g., COPD) prir diagnsis f central sleep apnea n evidence f ncturnal xygen (O2) desaturatins* caused by a cnditin ther than OSA (e.g. besity hypventilatin syndrme) E. Paramunt cvers fllw-up hme titratin using APAP when ALL f the fllwing criteria are met: n cmrbid cnditin that wuld be expected t degrade the accuracy f aut-titratin n evidence f ncturnal xygen desaturatin* caused by a cnditin ther than OSA (as described abve) prcedure t be perfrmed fr ANY f the fllwing: t determine whether pressure adjustment is needed when clinical respnse is insufficient r symptms return despite a gd initial respnse t PAP substantial weight lss (e.g., 10% f bdy weight) t determine if adjustment f PAP pressure is indicated substantial weight gain (e.g., 10% f bdy weight) with return f symptms despite cntinued use f CPAP, t determine if adjustment f PAP pressure is indicated * Significant xygen desaturatin: O2 saturatin < 80% fr > 1% f recrding time r < 90% fr > 20% f recrding time during prir diagnstic hme study O2 saturatin < 80% fr > 1% f sleep time r < 90% fr > 30% f sleep time during prir diagnstic facility-based study F. Paramunt des nt cver a hme/prtable sleep study fr any ther indicatin because it is cnsidered nt medically necessary. Adult Facility Sleep Study (95808, 95810, 95811) A. Paramunt cvers a sleep study as medically necessary fr the diagnsis f suspected bstructive sleep apnea (OSA) in an adult (age 18 r lder) when BOTH f the fllwing criteria are met: evidence f daytime sleepiness (e.g., excessive sleepiness nt explained by ther factrs, nn-refreshing sleep, sleep fragmentatin) ANY f the fllwing additinal symptms r risk factrs f OSA: witnessed apneas gasping r chking at night disruptive snring increased neck circumference (i.e., > 17 inches in men, > 16 inches in wmen) besity (i.e., bdy mass index 30) B. Paramunt cvers full night in-facility plysmngraphy (PSG) (95808, 95810) as medically necessary in an adult (age 18 r lder) when BOTH f the fllwing criteria are met: medical necessity criteria fr a sleep study fr suspected bstructive sleep apnea (OSA) as utlined abve have been met ANY f the fllwing: significant cmrbid cnditin that wuld be expected t degrade the accuracy f a hme/prtable study such as any f the fllwing

4 - 4 - mderate t severe pulmnary disease, such as chrnic bstructive pulmnary disease (COPD) mderate t severe neurmuscular/neurdegenerative disrder causing restrictive lung diseases (e.g., kyphsclisis, myasthenia gravis, amytrpic lateral sclersis (ALS), pli, plymysitis, Guillian Barre syndrme) cngestive heart failure (mderate t severe) besity hypventilatin syndrme, previusly dcumented pulmnary hypertensin sleep disrder ther than OSA is suspected (e.g., central sleep apnea, peridic limb mvement disrder, parasmnias, narclepsy, REM behavir sleep disrder) that is crrbrated by the clinical dcumentatin recent hme/prtable testing prved t be technically inadequate r failed t establish the diagnsis f OSA in an individual with high pretest likelihd f OSA individual and caregiver/cmpanin incapable f perating hme testing equipment C. Paramunt cvers full night in-facility plysmngraphy (PSG) (95808, 95810) as medically necessary prir t a planned multiple sleep latency test (MSLT) in an adult (age 18 r lder) with suspected narclepsy. D. Paramunt cvers split-night in-facility plysmngraphy (PSG) (95811), in which the initial diagnstic prtin f the PSG is fllwed by psitive airway pressure (PAP) titratin, as medically necessary in an adult (age 18 r lder) when ALL f the fllwing criteria are met: medical necessity criteria fr a sleep study fr suspected bstructive sleep apnea (OSA) as utlined abve have been met apnea/hyppnea index (AHI) r respiratry disturbance index (RDI) f 15 r higher during initial diagnstic prtin f split-night study, r AHI r RDI > 5 with symptms indicative f significant OSA (e.g., repetitive bstructins, significant xygen desaturatin [i.e. xygen saturatin < 80% fr >1% f sleep time r < 90% fr > 30% f sleep time during a diagnstic facility based PSG]) AHI r RDI is calculated based n at least tw hurs f cntinuus recrded sleep r, if calculated based n less than tw hurs f sleep, the ttal number f recrded events t calculate the AHI r RDI must be at a minimum the number f events that wuld have been required in a tw-hur perid. ANY f the fllwing: significant cmrbid cnditin that wuld be expected t degrade the accuracy f a hme/prtable study. such as any f the fllwing mderate t severe pulmnary disease, such as chrnic bstructive pulmnary disease (COPD) mderate t severe neurmuscular/neurdegenerative disrder causing restrictive lung diseases (e.g., kyphsclisis, myasthenia gravis, amytrpic lateral sclersis (ALS), pli, plymysitis, Guillian Barre syndrme) cngestive heart failure (mderate t severe) besity hypventilatin syndrme, previusly dcumented pulmnary hypertensin sleep disrder ther than OSA is suspected (e.g., central sleep apnea, peridic limb mvement disrder, parasmnias, narclepsy, REM behavir sleep disrder) and is crrbrated by the clinical dcumentatin recent hme/prtable testing prved t be technically inadequate r failed t establish the diagnsis f OSA in an individual with high pretest likelihd f OSA individual and caregiver/cmpanin incapable f perating hme testing equipment E. Paramunt cvers in-facility PSG (95811) fr PAP titratin, fllwing a prir diagnstic study as medically necessary in an adult (age 18 r lder) when ALL f the fllwing criteria are met: AHI r RDI 15 dcumented n prir PSG r hme/prtable study, r AHI r RDI 5 and < 15, with symptms f OSA (e.g., excessive daytime sleepiness, impaired cgnitin, md disrders r insmnia, r with hypertensin, ischemic heart disease r histry f strke AHI r RDI was calculated based n at least tw hurs f cntinuus recrded sleep r, if calculated based n less than tw hurs f sleep, the ttal number f recrded events t calculate the AHI r RDI was, at a minimum, the number f events that wuld have been required in a tw-hur perid. EITHER f the fllwing: a cmrbid sleep disrder (e.g., significant central sleep apnea [i.e., central sleep apneas/hyppneas > 50% f ttal apneas/hyppneas, r 5 central apneas/hyppneas per hur], peridic limb mvement disrder [> 15 peridic limb mvements per hur resulting in arusal], parasmnias, narclepsy, REM behavir sleep disrder) crrbrated by the clinical dcumentatin

5 - 5 - a significant cmrbid cnditin that wuld be expected t degrade the accuracy f a hme/prtable study, such as any f the fllwing mderate t severe pulmnary disease, such as chrnic bstructive pulmnary disease (COPD) mderate t severe neurmuscular/neurdegenerative disrder causing restrictive lung diseases (e.g., kyphsclisis, myasthenia gravis, amytrpic lateral sclersis (ALS), pli, Plymysitis, Guillian Barre syndrme) cngestive heart failure (mderate t severe) besity hypventilatin syndrme, previusly dcumented pulmnary hypertensin F. Paramunt cvers in-facility PSG (95811) fr re-titratin f PAP as medically necessary in an adult (age 18 r lder) when BOTH f the fllwing criteria are met: clinical respnse t PAP is insufficient r symptms return despite cmpliance with PAP therapy individual with significant xygen desaturatin* during diagnstic sleep study, r presence f a cmrbid sleep disrder r significant cmrbid medical cnditin as described abve * Significant xygen desaturatin: O2 saturatin < 80% fr > 1% f recrding time r < 90% fr > 20% f recrding time during prir diagnstic hme study O2 saturatin < 80% fr > 1% f sleep time r < 90% fr > 30% f sleep time during prir diagnstic facility-based study G. Paramunt des nt cver adult in-facility PSG fr any ther indicatin because it is cnsidered nt medically necessary. Child Hme Sleep Study (95800, 95801, 95806, G0398, G0399, G0400) A. Paramunt des nt cver a hme/prtable sleep study fr the diagnsis f OSA in a child because it is cnsidered experimental, investigatinal r unprven. Child Facility Sleep Study (95782, 95783, 95808, 95810, 95811) A. Paramunt cvers pediatric in-facility plysmngraphy (PSG) as medically necessary fr ANY the fllwing indicatins: bstructive sleep apnea (OSA) suspected based n clinical assessment fllwing adentnsillectmy in a child with mild preperative OSA with residual symptms f OSA fllwing adentnsillectmy t assess fr residual OSA in child with preperative evidence f mderate t severe OSA, besity, cranifacial anmalies that bstruct the upper airway, r neurlgic disrder (e.g., Dwn syndrme, Prader-Willi syndrme, myelmeningcele) titratin f psitive airway pressure (PAP) in a child with OSA suspected cngenital central alvelar hypventilatin syndrme r sleep related hypventilatin due t neurmuscular disrders r chest wall defrmities primary apnea f infancy evidence f a sleep related breathing disrder in infant wh has experienced an apparent life threatening event (ALTE). child being cnsidered fr adentnsillectmy t treat OSA fllw-up fr child n chrnic PAP supprt, t determine whether pressure requirements have changed due t grwth and develpment; if symptms recur while n PAP; r if additinal r alternate treatment is instituted assessment f respnse t treatment with an ral appliance nninvasive psitive pressure ventilatin (NIPPV) titratin in child with ther sleep-related breathing disrder (SRBD) evaluatin f child treated with mechanical ventilatin fr adjustment f ventilatr settings. evaluatin prir t decannulatin in child treated with trachestmy fr SRBD clinical suspicin f an accmpanying sleep related breathing disrder in a child with chrnic asthma, cystic fibrsis, pulmnary hypertensin, brnchpulmnary dysplasia, r chest wall abnrmality (e.g., kyphsclisis) B. Paramunt des nt cver pediatric in-facility PSG fr any ther indicatin because it is cnsidered nt medically necessary.

6 - 6 - Other Diagnstic Tests A. Paramunt cvers maintenance f wakefulness testing (MWT) (95805) as medically necessary t evaluate respnse t treatment fr bstructive sleep apnea, narclepsy, r peridic limb mvement disrder. B. Paramunt cvers multiple sleep latency testing (MSLT) as medically necessary fr the evaluatin f suspected narclepsy when ther sleep disrders have been ruled ut by PSG. C. Paramunt des nt cver MSLT r MWT (95805) fr the diagnsis f OSA because it is cnsidered nt medically necessary. Investigatinal and Nt Medically Necessary A. Paramunt des nt cver a hme/prtable sleep study (95800, 95801, 95806, G0398, G0399, G0400) fr the diagnsis f OSA in a child because it is cnsidered experimental, investigatinal r unprven. B. Paramunt des nt cver an in-facility plysmngraphy (PSG) r hme/prtable sleep study fr any f the fllwing indicatins because each is cnsidered experimental, investigatinal r unprven (this list may nt be all-inclusive): chrnic lung disease circadian rhythm disrders depressin seizures in the absence f symptms f sleep disrder transient r chrnic insmnia insmnia assciated with psychiatric disrders C. Paramunt des nt cver an abbreviated cardirespiratry sleep study t acclimate an individual t PAP (e.g., PAP-Nap) (95807) because it is cnsidered experimental, investigatinal r unprven. D. Paramunt des nt cver prescreening devices t predict pretest prbability f OSA prir t seeking a sleep study (e.g., SleepStrip, acustic pharyngmetry) because they are cnsidered experimental, investigatinal r unprven. CODING/BILLING INFORMATION The appearance f a cde in this sectin des nt necessarily indicate cverage. Cdes that are cvered may have selectin criteria that must be met. Payment fr supplies may be included in payment fr ther services rendered. CPT CODES Plysmngraphy; yunger than 6 years, sleep staging with 4 r mre additinal parameters f sleep, attended by a technlgist Plysmngraphy; yunger than 6 years, sleep staging with 4 r mre additinal parameters f sleep, with initiatin f cntinuus psitive airway pressure therapy r bi-level ventilatin, attended by a technlgist Sleep study, unattended, simultaneus recrding; heart rate, xygen saturatin, respiratry analysis (e.g., by airflw r peripheral arterial tne), and sleep time Sleep study, unattended, simultaneus recrding; minimum f heart rate, xygen saturatin, and respiratry analysis (e.g., by airflw r peripheral arterial tne) Actigraphy testing, recrding, analysis, interpretatin, and reprt (minimum f 72 hurs t 14 cnsecutive days f recrding) Multiple sleep latency r maintenance f wakefulness testing, recrding, analysis and interpretatin f physilgical measurements f sleep during multiple trials t assess sleepiness Sleep study, simultaneus recrding f ventilatin, respiratry effrt, ECG r heart rate, and xygen saturatin, unattended by a technlgist Sleep study, simultaneus recrding f ventilatin, respiratry effrt, ECG r heart rate, and xygen saturatin, attended by a technlgist Plysmngraphy; any age, sleep staging with 1-3 additinal parameters f sleep, attended by a technlgist Plysmngraphy; age 6 years r lder, sleep staging with 4 r mre additinal parameters f sleep, attended by a technlgist Plysmngraphy; age 6 years r lder, sleep staging with 4 r mre additinal parameters f sleep, with initiatin f cntinuus psitive airway pressure therapy r bi-level ventilatin, attended by a technlgist HCPCS CODES G0398 Hme sleep study test (HST) with type II prtable mnitr, unattended; minimum f 7 channels: EEG, EOG, EMG, ECG/heart rate, airflw, respiratry effrt and xygen saturatin G0399 Hme sleep test (HST) with type III prtable mnitr, unattended; minimum f 4 channels: 2 respiratry mvement/airflw, 1 ECG/heart rate and 1 xygen saturatin G0400 Hme sleep test (HST) with type IV prtable mnitr, unattended; minimum f 3 channels TAWG REVIEW DATES: 10/22/2015 REVISION HISTORY EXPLANATION 07/01/12: Verbiage updated t allw cverage fr members meeting criteria.

7 - 7-10/22/15: Title changed frm Hme Sleep Study Testing t Sleep Study Testing. Added cdes 95782, 95783, 95803, 95805, 95807, 95808, 95810, Plicy reviewed and updated t reflect mst current clinical evidence per TAWG. 05/09/18: Crrected typ. REFERENCES/RESOURCES Centers fr Medicare and Medicaid Services, CMS Manual System and ther CMS publicatins and services Ohi Department f Medicaid American Medical Assciatin, Current Prcedural Terminlgy (CPT ) and assciated publicatins and services Centers fr Medicare and Medicaid Services, Healthcare Cmmn Prcedure Cding System, HCPCS Release and Cde Sets Industry Standard Review Hayes, Inc.