Treatment of Obstructive Sleep Apnea (OSA)

Transcription

1 MP9239 Covered Service: Prior Authorization Required: Additional Information: Yes when meets criteria below Yes as shown below None Prevea360 Health Plan Medical Policy: 1.0 A continuous positive airway pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP) device requires prior authorization through the Health Services Division and is considered medically necessary when ordered by a pulmonologist, neurologist, or a physician board certified in sleep medicine for patients with a diagnosis of obstructive sleep apnea (OSA) diagnosed using a clinical evaluation and a positive polysomnograghy (PSG) performed in a sleep laboratory. 1.1 A positive airway pressure device (i.e. CPAP or BiPAP) based on clinical diagnosis alone or using a diagnostic procedure other than those in 1.0 will be considered not medically necessary. 2.0 For members ages 18 or older, a positive test for OSA is established if either of the following criteria using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is met: 2.1 AHI or RDI greater than or equal to 15 events per hour, OR 2.2 AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive day time sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. 2.3 If the AHI or RDI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a 2-hour period. 3.0 For members under the age of 18, an AHI or RDI of 1.5 or greater, combined with other findings such as habitual snoring, behavioral problems or obesity will be sufficient to consider CPAP usage. 4.0 CPAP may be initiated prior to 2 hours of sleep if apnea/hypopneas are observed associated with oxygen saturation of <60% or cardiac arrhythmia. 1 of 5

2 5.0 For members who meet criteria for CPAP, heated humidification or oxygen may be included without prior authorization 6.0 BiPAP, DPAP, VPAP, and AutoPAP are considered medically necessary DME for members who are intolerant to or not well controlled on CPAP 7.0 The DME vendor will check with the member for adherence to the therapy no sooner than the 31 st day, but no later than the 91 st day after initiating therapy. Compliance data should be submitted within 120 days of the member receiving the CPAP or BiPAP. 7.1 For adults, adherence to the therapy is defined as use of the CPAP or BiPAP greater than 4 hours per night on 70% of the nights during a consecutive 30 day period anytime during the first three months of initial use. 7.2 For those members under 18 years of age or adults with significant cognitive disabilities, adherence is defined as usage of CPAP or BiPAP on 70% of nights over a 30 day period. 7.3 If adherence to the therapy criteria as defined is not met, use of the CPAP or BiPAP will be considered not medically necessary 7.4 An additional 60 days of rental to improve compliance may be granted on a one time basis if the member has been using the CPAP or BiPAP and there is documentation that barriers to compliance have been or will be addressed (i.e. mask changed, equipment malfunction repaired, member sickness precluding use has improved, etc). 7.5 For members requesting purchase of a CPAP or BiPAP when no recent compliance data is available, rental may be approved instead for up to 91 days, so that compliance may be demonstrated as above. 8.0 An oral appliance (airway splint, mandibular advancement device or splint) requires prior authorization through the Health Services Division and is considered medically necessary when ALL of the following criteria are met:: 8.1 Used exclusively for treatment of OSA after failure of CPAP as documented by a Pulmonologist, Neurologist or a physician board certified in sleep medicine; 8.2 Reimbursement for a medically appropriate oral appliance is made only when it is not covered by a dental policy The term oral appliance is used as a generic term for devices inserted into the mouth in order to modify the position of the mandible, the tongue, and other structures in the upper airway for the purpose of relieving snoring or sleep apnea. 9.0 Uvulopalatopharyngoplasty (UPPP) requires prior authorization through the Health Services Division with Medical Director review and is considered medically 2 of 5

3 necessary for the treatment of obstructive sleep apnea (OSA) provided that patients meet ALL of the following criteria: 9.1 Severe OSA, defined as AHI > 15; 9.2 Moderate OSA, defined as an AHI between 10 and 14 with any one of the following associated symptoms: Excessive daytime sleepiness Documented impaired condition Mood disorders Insomnia Documented hypertension Pulmonary hypertension Ischemic heart disease History of stroke Epworth sleepiness scale score > Conservative measures of treatment, which must be documented in the medical record, must be exhausted first and include: Avoidance of alcohol Weight reduction Trial and intolerance of nasal CPAP, as well as BiPAP, DPAP, VPAP, and AutoPAP if appropriate Adequate response to trial of CPAP 9.4 A Pulmonologist, Neurologist or certified Sleep Medicine Specialist must concur with the need for UPPP UPPP may rarely be indicated for treatment of severe, refractory uvulopalatoangioedema after consultation with allergy Laser assisted uvulopalatoplasty (LAUP) and uvulectomy have not been shown to be as effective as UPPP in the treatment of OSA and therefore these surgeries are considered not medically necessary Exception: For some patients with severe OSA who have medical conditions that contraindicate UPPP and who have met criteria in 11.2, consideration of medical necessity of LAUP will be made on a case-by-case basis A Pulmonologist, Neurologist or certified Sleep Medicine Specialist must concur with the need for LAUP. 3 of 5

4 12.0 Patients being considered for UPPP, who have Upper Airway Resistance Syndrome but do not meet the usual RDI criteria for OSA, must be evaluated by a sleep specialist before authorization of the UPPP procedure is considered Radiofrequency ablation of the tongue base, uvula, or soft palate (somnoplasty); or of the nasal passages and soft palate (coablation) for treatment of OSA has not been shown to be effective. Therefore this treatment is not medically necessary The Repose System for treatment of OSA has not been shown to be effective. Therefore this treatment is not medically necessary Cautery-Assisted Palatal Stiffening Operation (CAPSO) for the treatment of OSA is considered experimental/investigational and therefore is not medically necessary Pillar Palatal Implant System for the treatment of OSA is considered experimental/investigational and therefore is not medically necessary. Committee/Source Date(s) Originated: Utilization Management Committee June 14, 2000 Revised: Utilization Management Committee Department/ DMERC Supplier Bulletin, 3/2002 Utilization Management Committee/Medical Affairs/Sleep Specialist Utilization Management Committee/Medical Affairs/Sleep Specialist February 14, 2001 June 12, 2002 November 12, 2003 March 10, 2004 April 12, 2006 October 11, 2006 June 11, 2008 November 12, 2008 November 11, 2009 June 9, 2010 June 16, 2010 July 21, 2010 April 17, 2013 July 17, 2013 September 17, 2014 July 15, 2015 February 17, 2016 March 16, of 5

5 Revised: Reviewed: Committee/Source Medical Policy Committee/Health Services Division Managed Care Division/ Medical Affairs Department Utilization Management Committee/CMO/Director UM UM Committee (UMC)/Director UM/ UMC Chair Reformatted Medical Policy Committee/Health Services Division Date(s) May 17, 2017 June 21, 2017 July 19, 2017 August 15, 2018 April 11, 2001 March 13, 2002 March 12, 2003 March 9, 2005 March 8, 2006 March 2006 March 14, 2007 March 12, 2008 April 8, 2009 June 16, 2010 July 21, 2010 July 27, 2011 July 18, 2012 August 15, 2012 April 17, 2013 July 17, 2013 July 16, 2014 September 17, 2014 July 15, 2015 February 17, 2016 March 16, 2016 July 20, 2016 May 17, 2017 June 21, 2017 July 19, 2017 August 15, 2018 Published/Effective: 09/01/ of 5