Medical Affairs Policy

Transcription

1 Medical Affairs Policy Service: Sleep Disorder Treatment: Positive Airway Pressure Devices and Oral Appliances (CPAP, BPAP, BiPAP, BiPAP ST, BiPAP with backup, BiPAP -Auto SV, VPAP, VPAP Adapt, VPAP adapt SV, APAP, Adaptive Servo- Ventilation, ASV, oral device, mandibular advancement device) PUM Medical Policy Committee Approval 12/01/17 Effective Date 04/01/18 Prior Authorization Needed Yes Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, medical.policies@wpsic.com. Note: Coverage for PAP and related devices are subject to the individual s health plan language for Durable Medical Equipment (DME) Description: This policy addresses the following treatments: An Oral Appliance, also called: mandibular advancement device (MAD), mandibular advancement appliance (MAA), mandibular repositioning appliances (MRA), or mandibular advancement splint (MAS), is a device used to modify an individual s airway during sleep to decrease the symptoms associated with obstructive sleep apnea (OSA). Positive Airway Pressure (PAP) devices provide respiratory assistance through the administration of positive air pressure through a nasal or oral mask for the treatment of sleep disordered breathing. The most common condition treated with PAP is obstructive sleep apnea. Central Sleep Apnea (CSA) and Complex Sleep Apnea (CompSA- also known as treatment emergent central sleep apnea ), are less common. CSA can be further described as hyperventilation related (e.g. Cheyne-Stokes breathing) or hypoventilation related (e.g. nervous system related disease or drug use). The PAP device is set to generate an airway pressure that maintains an open airway and minimizes sleep-related apneas and low oxygen levels (hypopneas). Several categories of PAP devices are available: Page 1 of 14

2 CPAP (continuous positive airway pressure) provides a continuous set level of airway pressure during both inspiration and expiration. BPAP (bi-level positive airway pressure) provides positive airway pressure at a set level during inspiration, but allows a different level of positive airway pressure to be set during expiration, available with and without back up features. ASV (adaptive-servo-ventilation) provides a varying amount of inspiratory pressure superimposed on a low level of CPAP, with a backup respiratory rate. It is used as second-line therapy for patients with hyperventilation-related central sleep apnea who have failed or do not tolerate CPAP. Automatic Positive Airway Pressure (APAP): also called CPAP with autotitration, autopap, and auto-titrating positive airway pressure, can be used to titrate PAP therapy in the patient s home. The device is set up within a wide range of pressures and the patient is sent home to use the device for a specified time (usually 2-4 weeks). Some devices have computerized algorithms to monitor, adjust, record, and report pressures needed to respond to breathing events. Models vary widely, including some that can report AHI and identify episodes of Central Apnea. This information can be used to determine the fixed CPAP pressure for a CPAP device. In some instances, the patient will continue to use the APAP device to treat their sleep apnea. VPAP (variable positive airway pressure) devices provide variable levels of airway pressure during inspiration and expiration, responding to the needs of the individual. Definitions: Apnea is defined as >90 percent reduction in peak signal excursion of the airflow sensor for >10 seconds on the recording device. Hypopnea is defined as >30% reduction in excursion of the airflow sensor lasting for >10 seconds and associated with 3 percent oxygen desaturation on the recording device. Apnea Hypopnea Index (AHI) is defined as the number of obstructive apneas and hypopneas per hour of recorded sleep. This is typically reported as the average number of apneas and hypopneas per hour during a (two-hour minimum) polysomnogram. AHI equals (hypopneas + apneas) X 60 / Total Sleep Time (TST) in minutes. Obstructive Sleep Apnea(OSA) is a sleep related breathing disorder that involves a decrease in, or complete lack of, airflow, despite an ongoing effort to breath. The Page 2 of 14

3 severity of OSA is divided into three categories based on the result of the PSG. Mild (AHI of 5-15), Moderate (AHI of 15-30) and Severe (AHI of over 30) Respiratory Disturbance Index (RDI) is defined as the total number of apneas, hypopneas, and respiratory event-related arousals (RERAs) per hour of sleep on a full in lab PSG. RDI reported on a home study includes only apnea and hypopneas because RERAs cannot be calculated in a home study. RDI values are not equivalent to AHI values. However, the home RDI score may be roughly equivalent to AHI score because the score does not include RERAs. The more appropriate term is Respiratory Event Index REI. Respiratory Event Index (REI)-index used to describe the number of apneas and hypopneas when using a Home Sleep Apnea Test (HSAT) per total recording time. Respiratory event-related arousals (RERA s) are respiratory event related arousals from sleep that may be seen during a sleep study with EEG. The degree of hypoxia is not low enough to fulfill the criteria for apnea or hypopnea, but does result in brief arousal. Severe COPD is typically defined as: post bronchodilator FEV1/FVC ratio <0.7, FEV1 <30 percent predicted. Sleep Medicine Specialist: For purpose of this policy, a sleep medicine specialist is one of the following: o A Diplomate of the American Board of Sleep Medicine or o A certification in sleep medicine and one of the following Board-Certified Specialties: Pulmonologist, Otolaryngologist, Neurologist, Pediatrician, Internist, Family Medicine Physician, or Psychiatrist; or Nurse Practitioner or Physician Assistant working in collaboration with one of the listed specialists. Monitoring Devices are classified by technologic capability. Classification is based on the number of sleep related parameters and channels of parameters the device can measure and record. Portable monitoring devices (PMD) vary widely in their technology and manufacturer description of channels. Type I devices are the most complex devices used primarily in laboratory technician attended overnight PSG. Type II-IV PMD have fewer channels and are used for home PSG. For the purposes of this policy: Type II PMD must have a minimum of 7 channels which include EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and O2 saturation. Page 3 of 14

4 Type III PMD must have capability to measure and record a minimum of 4 channels including two measures of respiratory movement/airflow, one measure of ECG/heart rate and one measure of O2 saturation. They typically lack the (EEG) ability to detect arousal from sleep or REM sleep. Type IV devices have variable (1-3) parameters such as O2 saturation and airflow and are considered insufficient for home study and unproven to affect health outcomes. Compliance, for the purpose of this policy is defined as a minimum of four hours of use per night for 70% of the nights of a three-month trial. Several studies have assessed treatment adherence to PAP devices. Estimates for non-compliance, defined as 4 hours per night, range from 29-83%. In general, rate of compliance with the various devices are similar, even when respiratory measures are improved. Early intervention with a BPAP device after poor initial experience with in lab CPAP does not appear to result in improved utilization of the PAP device. Due to the substantial rates of noncompliance, a three-month trial rental of PAP device to optimize compliance is required prior to purchase of PAP and approval of Oral Appliance devices. Indications of Coverage: A. AutoPAP (APAP) or CPAP with or without a humidifier (heated or non-heated) is considered medically necessary for the treatment of any of the following conditions (see section V. for additional APAP indications) 1. Obstructive sleep apnea that has been diagnosed though a Type I, II, or III polysomnogram with an in-lab AHI or home study RDI or REI (as defined above) of 15 or more. 2. Obstructive sleep apnea that has been diagnosed though a Type 1 (recommended), Type II, or Type III polysomnogram with an in-lab AHI or home study RDI (as defined above) between 5 and 15 and: The individual has at least one of the following co-morbidities or symptoms: a. Presence of cardiac arrhythmias unstable or refractory to treatment b. Unexplained pulmonary hypertension c. Hypertension d. Body mass index (BMI) greater than 40 e. Cerebrovascular disease (Stroke) Page 4 of 14

5 f. Congestive Heart Failure (CHF) includes NYHA class III or IV, LVEF under 45%) g. Excessive Daytime Sleepiness defined as an Epworth score over 10 h. Cognitive dysfunction attributed to sleep diagnosed using one of the following clinically recognized cognitive assessment tools: 1) California Verbal Learning Test 2) Digit Span (from the Wechsler Adult Intelligence Scale-Revised) 3) Informant Questionnaire on Cognitive Decline in the Elderly 4) Mini-Mental State Examination (MMSE) 5) Montreal Cognitive Assessment (MoCA) test 6) Trails A or B OR 7) Current use of medication for dementia i. Depression requiring antidepressant therapy j. Ischemic Heart Disease B. BPAP (BiPAP) without back up with or without a humidifier is considered medically necessary for the treatment of any of the following conditions: 1. OSA: Member met the criteria above for CPAP and either of the following: a. Documentation from a sleep medicine physician reporting the failure of a onemonth trial of CPAP or AutoPAP due to intolerance to high pressures that exceed 10cm H2O despite adequate changes to headgear and masks. A download from the CPAP device documenting a minimum of four hours of use per night for 70% of the nights of the trial is required. b. Documentation from a laboratory titration study indicating failure with CPAP, or documentation of AutoPAP failure, to meet therapeutic goals (e.g. BPAP needed due to inadequate reduction of AHI or hypoxia with CPAP, as may occur with amyotrophic lateral sclerosis, severe COPD, chronic hypercapnic respiratory failure, obesity hypoventilation syndrome, or chronic opioid use). C. BPAP with back up is considered medically necessary for the treatment of the following conditions when prescribed by a Sleep Medicine Specialist. 1. Neuromuscular disease (for example, amyotrophic lateral sclerosis) OR Significant thoracic anatomical abnormalities (e.g. post thoracic surgery deformity), when there is documentation from laboratory attended PSG indicating failure of BPAP Page 5 of 14

6 without back up to meet therapeutic goals, and there is significant improvement of sleep associated hypoventilation on the device prescribed for use at home. 2. Severe COPD: when there is documentation from laboratory attended PSG indicating failure of BPAP without back up to meet therapeutic goals, and there is significant improvement of sleep associated hypoventilation on the device prescribed for use at home. 3. Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA) documented by a laboratory attended PSG, when use of CPAP alone has proved ineffective, and there is significant improvement of sleep associated hypoventilation/ hypoxia on the device and setting that will be prescribed for use at home. D. Adaptive Servo Ventilation: (e.g. VPAP Adapt (with Adaptive Servo Ventilation (ASV)) or BiPAP (with auto Servo Ventilation (SV)) are considered medically necessary when there is documentation that BPAP with or without backup has failed; or is contraindicated, and there is significant improvement during laboratory titration, on the device that has been prescribed for the treatment of any of the following conditions. The device must be prescribed by a Sleep Medicine Specialist: 1. Primary Central Sleep Apnea (does not require BPAP trial) 2. Central Sleep Apnea except in patients with symptomatic heart failure with 3. Left ventricular ejection fraction (LVEF) 45% 4. Complex Sleep Apnea or treatment emergent central sleep apnea 5. CHF 6. Hypoventilation syndrome E. APAP with or without a humidifier may also be considered medically necessary for any of the following conditions: 1. When prescribed by a sleep medicine physician for an individual with continued symptoms of obstructive sleep apnea that are documented in the medical record despite a two-month trial of ongoing use of CPAP or BPAP. A download from the PAP device currently being used that documents a minimum of four hours of use per night for 70% of the nights of the trial, and documentation that issues with mask fit and PAP intolerance have been addressed, is required. (Allow up to 3 months of rental for evaluation and titration changes.) Page 6 of 14

7 2. When prescribed by a sleep medicine physician following a laboratory polysomnogram that diagnosed obstructive sleep apnea with an AHI of at least 5, but there was insufficient time to complete a split night study for CPAP titration. (Allow up to 3 months of rental for evaluation and titration changes). For all devices: A rental of three months may be approved. Documentation (device download) of a minimum of four hours of use per night for 70% of the nights of the trial must be submitted with a prior authorization request for purchase of the CPAP prior to the end of the three-month rental. Continued rental beyond three months will not be approved. Payment of rental charges beyond the purchase price of the device is a limitation of many of our member health plans and provider contracts. Replacement of PAP devices: Review member s certificate for replacement purchase versus repair of PAP devices. Documentation should include the reason replacement is needed (submit repair / replacement estimate when applicable). Medical records should include history- indications for the original CPAP (for example AHI, Epworth scores when available), recent use history and effectiveness of PAP (or change in symptoms if the device is not working). Replacement needed due to misuse or abuse or member convenience are not covered. F. An Oral Appliance for an adult is considered medically necessary when all the following criteria are met: 1. A polysomnogram documented the presence of mild or moderate (e.g. AHI below 30) obstructive sleep apnea sufficient to meet criteria for the use of a Positive Airway Pressure (PAP) device. 2. A two-month trial of the PAP device has failed. Failure of the PAP trial is defined as intolerance of the high pressures needed to maintain airway patency despite documentation of appropriate interventions to improve compliance (e.g. changes to masks and headgear, and support to address side effects and behavioral issues). The documentation must support that the individual has been compliant with recommendations for PAP device use, as evidenced by a download from the PAP device that documents a minimum of four hours of use per night for 70% of the nights of the trial. 3. A custom-fitted or prefabricated oral appliance is prescribed in the context of a comprehensive sleep program, after an evaluation by a Sleep Medicine Specialist. The evaluation must include documentation of PAP intolerance or contraindication. 4. The device is provided by a licensed dentist AND there is documentation of: a. Sufficient dentition to allow for retention of the appliance Page 7 of 14

8 b. No active periodontal disease or dental decay c. No active temporomandibular joint disorder d. No restriction in mandibular opening or protrusion Note: Aside from one follow up home polysomnogram to insure therapeutic benefit after final fitting/adjustment of the device, all follow up care including (but not limited to) adjustments, modifications, titration studies of a titratable device, and professional services are considered incidental to / included in the oral appliance (primary service). Only one Oral Appliance or PAP device will be approved for use at the same time. Deny per certificate language. In the absence of specific certificate language deny as not medically necessary. Replacement of Oral Appliance: Review member s certificate for replacement purchase versus repair of OA device. Documentation should include the reason replacement is needed (submit repair / replacement estimate when applicable). Medical records should include history- indications for the original device (for example AHI, Epworth scores when available), recent use history and effectiveness of device (or change in symptoms if the device is not working) Replacement needed due to misuse or abuse or member convenience are not covered. Limitations of Coverage: A. Review contract and endorsements for exclusions and prior authorization or benefit requirements (Note: for medical diagnoses, the oral appliance would not process under the dental benefit.) B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, deny as experimental, investigational, and unproven to affect health outcomes. C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, deny as not medically necessary D. An oral appliance for the treatment of snoring without documentation of obstructive sleep apnea is not a covered benefit as snoring is not considered to be an illness or injury E. An oral appliance is considered not medically necessary in any of the following situations: 1. When there is no polysomnogram documenting the presence of obstructive sleep apnea Page 8 of 14

9 2. In the absence of the failure of a two-month trial of CPAP 3. When the device is obtained over-the-counter without a prescription F. ASV to treat central sleep apnea in patients with symptomatic, chronic heart failure (NYHA 2-4) with reduced left ventricular ejection fraction (LVEF) 45% and moderate to severe predominant central sleep apnea is contraindicated. G. The following are considered experimental, investigational, and unproven to affect health outcomes or not covered per the member health plan: 1. Expiratory Positive Airway Pressure [EPAP] (e.g. Provent nasal dilator) 2. Nasal dilators 3. Oral Pressure Therapy (OPT) or Oral Pressure appliance treatments intended to regulate oral pressure to treat OSA (e.g. Winx Sleep Therapy System) 4. Hypoglossal Nerve Stimulation (inspire Upper Airway Stimulation) 5. Silent Partner noise canceling device to suppress snoring 6. Cleaning supplies and devices for PAP equipment or oral appliances (e.g. SoCLean 2 CPAP Cleaner and Sanitizing Machine) 7. Unilateral Phrenic Nerve Stimulation for Central Sleep Apnea Documentation Required: Sleep study report Medical records documenting comorbidities or other issues relevant to use of the PAP device Respiratory Therapy notes supporting compliance or intolerance issues (if applicable) Prescription or documentation from the physician describing the necessity of the device References: Positive Airway Pressure Devices 1. Aurora RN; Chowdhuri S; Ramar K; Bista SR; Casey KR; Lamm CI; Kristo DA; Mallea JM; Rowley JA; Zak RS; Tracy SL. The treatment of central sleep apnea Page 9 of 14

10 syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. SLEEP 2012;35(1): Carnevale C, Georges M. Rabec C et.al. Effectiveness of Adaptive Servo Ventilation in the treatment of hypocapnic central sleep apnea of various etiologies Sleep Med 2011 Dec 12 (10) Farid-Moayer M, Siegel L, Black J. A feasibility evaluation of oral pressure therapy for the treatment of obstructive sleep apnea. Ther Adv Respir Dis Feb; 7 (1):3-12. Available at: Accessed 12 Nov Lettieri CF, Lettieri CJ, Carter K, Does home sleep testing impair continuous positive airway adherence in patients with obstructive sleep apnea? Chest 2011 Apr; 139(849-54) Available at Accessed 12 Nov Parthasatathy S. Complex Sleep Apnea UpToDate Topic last updated: Oct.30, Powell E, Gay P, Ojile J et.al. A pilot study assessing adherence to auto bi-level following a poor initial encounter with CPAP. Journal of Clinical Sleep Medicine 2012 Feb 15 8(1): Available at: Accessed 12 Nov Qaseem A, Holty J, Owens D, et.al. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med 2013: Krakow B, Krakow J, Ulibarri V and McIver N. Frequency and Accuracy of RERA and RDI Terms in the Journal of Clinical Sleep Medicine from 2006 through J Clin Sleep Med. Feb 15, 2014; 10 (2): UpToDate. Adherence to continuous positive airway pressure. Literature review current through: Oct Topic last updated Sep 13, UpToDate. Management of sleep apnea in adults. Literature review current through: Oct Topic last updated Aug 22, UpToDate. Management of sleep apnea in children. Literature review current through: Oct Topic last updated Dec 9, MCG 21st Edition. ACG-A-0431 Noninvasive Positive Pressure Ventilation (CPAP, BiPAP) Page 10 of 14

11 13. UpToDate. Central sleep apnea: Treatment. Literature review current through: Oct Topic last updated Oct 26, UpToDate. Downloading data from PAP devices in adults. Literature review current through: Sep Topic last updated Jan 23, UpToDate. Treatment emergent central sleep apnea. Literature review current through Sept Topic last updated Feb 1, UpToDate. What s new in sleep medicine. Literature review current through Oct Topic last updated Nov 6, American Academy of Sleep Medicine Special Safety Notice August 2015 Accessed at MCG Ambulatory Care 21 st Edition. ACG-A-0337 CPAP Titration, Home (APAP) 19. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3): Novel Devices 1. Hayes Health Technology Brief. Hypoglossal Nerve Stimulation (Inspire Upper Airway Stimulation; Inspire Medical Systems Inc.) for Treatment of Obstructive Sleep Apnea Published Nov 6, Annual Review: September 28, 2015, Archived Mar 24, Report revised to MTD. See reference #3 2. Hayes Search and Summary. Oral Pressure Therapy for Treatment of Obstructive Sleep Apnea. Sept 25, Report archived on Oct 25, 2014 Hayes Health Technology Brief. 3. Hayes Medical Technology Directory. Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea. Published Mar 24, Annual review March 22, Hayes Prognosis Overview. Remede System for Central Sleep Apnea. Prognosis Snapshot Oct 18, 2017 Page 11 of 14

12 5. UpToDate. What s new in sleep medicine. Literature review current through Oct Topic last updated Nov 6, 2017 Oral Appliances 1. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for An American Academy of Sleep Medicine Report Available at: dfaccessed: 29 Aug Ferguson KA; Cartwright R; Rogers R Et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP 2006;29(2): CMS-LCD L28606 Oral Appliances for Obstructive Sleep Apnea Noridian Healthcare Solutions. Revised 11/1/13. Available at: Accessed 26 Nov Hayes Medical Technology Directory. Mandibular Advancement Devices for Sleep Apnea. Annual review July 14, Report Archived on Sep 17, UpToDate Oral appliances in the treatment of Obstructive Sleep apnea in adults. Literature review current through Sep Topic last updated Jan 27, Sutherland K, Vanderveken OM, Tsuda H et al: on behalf of the ORANGE registry. Oral Appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014; 10(2) Accessed 11/21/14. Available at: 7. MCG Ambulatory Care 21 st Edition. ACG-A-0341 Oral Appliances (Mandibular Advancement Devices) 8. Ramar K, Dort L, Katz S, et.al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015 An American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guideline Archived References: Page 12 of 14

13 1. Allam JS, Olson EJ, Gay PC, Morgenthaler TI. Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest Dec;132(6): American Academy of Neurology (AAN). Assessment: Techniques associated with the diagnosis and management of sleep disorders. Report of the Therapeutics and Technology Assessment Subcommittee. Neurology. 1992; 42: Available at: Accessed: 22 Jul Ayas NT, Patel SR, Malhotra A, Schulzer M, Malhotra M, Jung D, Fleetham J, White DP. Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep Mar 15;27(2): Berry R, Parish J, Hartse M. An American Academy of Sleep Medicine Review. The use of auto-titrating continuous positive airway pressure for treatment of adult obstructive sleep apnea. Sleep. 2002;25(2): Gay P, Weaver T, Loube D, Iber C. Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep Mar 1;29(3): Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR, Schubert NM, Redline S, Henry JN, Getsy JE, Dinges DF. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis Apr; 147(4): Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, Boehlecke B, Brown TM, Coleman J Jr, Friedman L, Kapen S, Kapur VK, Kramer M, Lee-Chiong T, Owens J, Pancer JP, Swick TJ, Wise MS; American Academy of Sleep Medicine. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep related breathing disorders. Sleep Mar 1;29(3): Littner M, Hirshkowitz M, Davila D, Anderson WM, Kushida CA, Woodson BT, Johnson SF, Merrill SW; Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report. Sleep Mar 15;25(2): Morgenthaler TI, Nisha-Aurora R, Brown T, Zak R, Alessi C, Boehlecke B, Chesson AL, Friedman L, Kapur V, Maganti R, Owens J, Pancer J, Swick TJ, Standards of Practice Committee of the AASM. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating Page 13 of 14

14 pressures and treating adult patients with obstructive sleep apnea syndrome: an update for Available at: Accessed: 22 Jul NHIC Corp. Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. LCD L Hingham, MA. Effective date: 09/01/09. Available at: _ _PA_ _rev_ pdf. Accessed: 22 Jul Nilius G, Happel A, Domanski U, Ruhle KH. Pressure-relief continuous positive airway pressure vs constant continuous positive airway pressure: a comparison of efficacy and compliance. Chest Oct;130(4): No authors listed. Indications and standards for use of nasal continuous positive airway pressure (CPAP) in sleep apnea syndromes. American Thoracic Society. 13. Official statement adopted March Am J Respir Crit Care Med Dec;150(6 Pt 1): Nolan GM, Doherty LS, McNicholas WT. Auto-adjusting versus fixed positive pressure therapy in mild to moderate obstructive sleep apnea. Sleep Feb 1;30(2): Patruno V, Aiolfi S, Constantino G, Murgia R, Selmi C, Malliani A, Montano N. Fixed and autoadjusting continuous positive airway pressure treatments are not similar in reducing cardiovascular risk factors in patients with obstructive sleep apnea. Chest WPS / Arise Review History: Implemented 04/01/15, 04/01/16, 01/01/17, 04/01/18 Medical Policy 12/13/13, Erratum corrected 03/31/14, 12/12/14, 12/12/15, Committee 12/09/16, 12/01/17 Approval Reviewed 12/12/14, 12/12/15, 12/09/16, 12/01/17 Developed Note: For review/revision history prior to 2014 see previous Medical Policy or Coverage Policy Bulletin Page 14 of 14