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The diagnosis of certain sleep related disorders such as sleep apnea is most definitely established by performing polysomnography. This is distinguished from other sleep studies by the inclusion of sleep staging which include a 1 - 4 lead electroencephalogram (EEG), an electro-oculogram (EOG) and a submental electromyogram (EMG). Supervision of the test is considered important to ensure the monitors are attached appropriately to the patient and do not become dislodged during the night. In addition, an attendant can identify severe OSA so that the effective level of continuous positive airway pressure (CPAP) therapy can be determined. These studies are known as "split-night" studies, in which the diagnosis of OSA is established during the first half of the night and CPAP titration is conducted during the second half of the night. If successful, this strategy can eliminate the need for an additional polysomnogram for CPAP titration.

Sleep studies and polysomnography are the continuous recording, analysis and interpretation of multiple simultaneous physiological measurements of sleep. Sleep studies monitor parameters of sleep that include: (1) EKG/ECG; (2) airflow; (3) ventilation and respiratory effort; (4) measurements of O2 saturation; (5) extremity muscle activity; (6) extended EEG monitoring; (7) snoring; (8) body positions, etc.

Polysomnography and Multiple Sleep Latency Testing (MSLT), when medically necessary and required by the member's plan document, must be performed in an AASM approved sleep disorders center/lab (See definition below). Such facilities may be hospital affiliated or freestanding effective. Services rendered at these clinics are generally short stays of not less than four hours and not more than twenty-four hours.

One polysomnogram is needed to confirm a diagnosis of OSA. A second polysomnogram may be required to adjust the CPAP device or in conjunction with a Sinemet trial for periodic leg movement. Additional polysomnograms may be necessary for evaluating treatment response and making subsequent treatment management decisions. More than three polysomnograms in a 12 month period should undergo utilization review.

Multiple sleep latency testing (MSLT) is considered medically necessary only to exclude or confirm the suspected diagnosis of narcolepsy. It should be done only after polysomnography. Multiple sleep latency testing (MSLT) is considered not medically necessary for routine screening, diagnosis or follow-up for sleep apnea.

Sleep disorder centers must meet the following criteria:

1. Effective January 1999, it is a facility, either affiliated with a hospital or freestanding, that;

Testing can be accomplished in any AASM certified center or lab.

The only accredited (approved) centers in Mississippi for patients meeting conditions described in POLICY are (as of the last revision of this policy):

AASM centers are accredited to provide a full range of diagnostic and therapeutic techniques for sleep disorders. BCBSMS medical policy limits services to the following, when meeting the criteria described in policy:

  OR  

Is accredited as a sleep disorder laboratory by the AASM. This facility may only provide diagnostic and treatment services for sleep-related breathing disorders, such as obstructive sleep apnea syndrome. This lab will have a physician who is certified by the American Board of Sleep Medicine within three (3) years after the date of the initial accreditation.

The only accredited (approved) labs in Mississippi for patients meeting conditions described POLICY (as of the last revision of this policy):

ASSM labs are accredited to provide a full range of diagnostic and therapeutic techniques for sleep-related breathing disorders. BCBSMS medical policy limits services to the following, when meeting the criteria described in policy.

2. Patients are referred to the sleep disorder clinic by the attending physician.

3. The need for polysomnography is confirmed prior to the study by a physician at the sleep disorder clinic.

4. There should not be duplication of previous testing performed by the attending physician, to the extent the results are still pertinent.

5. A sleep technician is present whenever testing is performed.

Polysomnography must be performed in an approved sleep disorders clinic and must include measurements of O2 saturation, EKG/ECG, EEG, EMG, EOG and airflow and respiratory effort.

The following services are considered investigational and not eligible for coverage:

1. Home portable sleep studies
2. Topographic EEG Mapping – see separate medical policy
3. Electrosleep therapy
4. Unattended (unsupervised) sleep studies

Medical Management 

Proposed treatments for the medical management of OSA include weight loss and nasal continuous positive airway pressure (CPAP). CPAP may be considered medically necessary in adult or pediatric patients with clinically significant OSA.

Auto-adjusting CPAP may be considered medically necessary during a 2-week trial to initiate and titrate CPAP in adult patients with clinically significant OSA.

Bilevel positive airway pressure or auto-adjusting CPAP may be considered medically necessary in patients with clinically significant OSA AND who have failed a prior trial of CPAP or for whom BiPAP is found to be more effective in the sleep lab.

CPAP, BiPAP and DPAP are considered medically necessary treatments in the medical management of OSA or in patients who do not have sleep apnea, but who have restrictive lung disease and documented desaturation at night, requiring nocturnal ventilation when diagnosed in an AASM approved sleep facility.

Intra-oral prostheses for patients with moderate to severe OSA (apnea-hypopnea index = 15, or apnea-hypopnea index <15 with significant hypoxemia) who have failed the 30 day trial of CPAP are medically necessary (added 5-16-2002)

Atrial pacing is considered investigational in the treatment of obstructive sleep apnea.

A nasal expiratory positive airway pressure (EPAP) device is considered investigational.

Surgical Management 

Surgery is not the first treatment of choice for OSA. It is reserved for patients who have failed all forms of medical management of OSA, including nasal continuous positive airway pressure (CPAP). Medical management must be attempted for a minimum of 30 days before any surgical management will be covered by the subscriber's policy.

There are multiple surgical procedures available for treatment of OSA:

1. Uvulopalatopharyngoplasty (UPPP)

UPPP involves surgical resection of the mucosa and submucosa of the soft palate, tonsillar fossa, and the lateral aspect of the uvula. The amount of tissue removed is individualized for each patient as determined by the potential space and width of the tonsillar pillar mucosa between the 2 palatal arches.

UPPP includes several technical variations. All include the basic UPPP procedure, but often additional surgery is performed, such as tonsillectomy or septoplasty. The UPPP enlarges the oropharynx but cannot correct obstructions in the hypopharynx. Thus patients who fail UPPP may be candidates for additional procedures, depending on the site of obstruction. Additional procedures include hyoid suspensions, maxillary and mandibular osteotomies, or modification of the tongue.UPPP with inferior sagittal osteotomy with hyoid suspension is one variation proposed to improve the surgical outcome.

Uvulopalatopharyngoplasty (UPPP), with or without inferior sagittal osteotomy (ISO) with hyoid suspension, is medically necessary for the treatment of obstructive sleep apnea syndrome in patients who have not responded or do not tolerate nasal continuous positive airway pressure (CPAP). Hyoid myotomy is considered medically necessary based on the same criteria (added 2-10-2004). Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery may be considered medically necessary in appropriate selected patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded or do not tolerate CPAP.

Clinically significant OSA is defined as either:

• An AHI > 15; OR
• An AHI between 5 and 14 with any of the following associated symptoms:
  • Excessive daytime sleepiness
  • Impaired cognition
  • Mood disorders
  • Insomnia
  • Documented hypertension
  • Ischemic heart disease
  • History of stroke

2. Laser-assisted Uvulopalatoplasty (LAUP)

Laser-assisted uvulopalatoplasty (LAUP) uses a carbon dioxide laser to obliterate tissue in the posterior pharynx.

Laser-assisted uvulopalatoplasty is considered investigational for the treatment of obstructive sleep apnea syndrome.

3. Adenotonsillectomy may be considered medically necessary in pediatric patients with clinically significant OSA and hypertrophic tonsils. Clinically significant OSA is defined as those pediatric patients who have:
   • AHI or RDI of at least 5 per hour, or
   • AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems, or hyperactivity.

4. Soft Palate Somnoplasty/Radiofrequency Tongue Base Reduction (Radiofrequency volumetric tissue reduction of the tongue and/or Radiofrequency volumetric tissue reduction of the palatal tissues)

Soft Palate Somnoplasty, also known as radiofrequency-mediated tongue tissue reduction or the Somnoplasty System ^TM, involves the insertion of a needle that emits radiofrequency energy (RFe) to the tissue in the tongue base. The temperature of the needle heats the surrounding tissue which coagulates and is reabsorbed by the body. Ultimately, the volume of tongue tissue is reduced. Multiple sessions are required over an eight-week period. In some situations, radiofrequency of the soft palate and base of tongue are performed together as a multilevel procedure.

Soft Palate Somnoplasty, also known as radiofrequency-mediated tongue tissue reduction, Somnoplasty System^TM (added 10/18/99), or Radiofrequency Tissue Volume Reduction (RFTVR), and radiofrequency volumetric tissue reduction of the palatal tissues whether performed together or alone is considered investigational for the treatment of obstructive sleep apnea syndrome.

4. Mandibular Maxillary Advancement (MMA)

MMA surgery is a more aggressive surgical procedure than UPPP. It has been used to relieve obstruction in OSA patients who have not responded to UPPP.

MMA surgery is considered medically necessary for the treatment of OSA in patients who have failed UPPP.

5. Tracheostomy

Tracheostomy is appropriate when reserved for patients with severe sleep apnea not manageable by any other intervention.

6. Palatal Stiffening Procedures

Palatal stiffening procedures include a cautery assisted palatal stiffening operation (CAPSO) and insertion of palatal implants. The CAPSO procedure uses cautery to induce a midline palatal scar designed to stiffen the soft palate to eliminate excessive snoring.  The Pillar^TM Palatal Implant System (Restore Medical, St Paul, MN) is an implantable device that has been cleared by the FDA 510(k) process. The device is a cyclindrical shaped segment of braided polyester filaments that is permanently implanted submucosally in the soft palate. The labeled indication of the device is as follows (3-31-2005):

"The Pillar^TM Palatal Implant System is intended for the reduction of the incidence of airway obstructions in patients suffering from mild to moderate OSA (obstructive sleep apnea)."

Palatal stiffening procedures, including but not limited to, cautery assisted palatal stiffening operation, and the implantation of palatal implants, are considered not medically necessary in the treatment of snoring alone, and are considered investigational as a treatment for upper airway resistance syndrome or OSA.

Note: Simple snoring in the absence of documented obstructive sleep apnea is not considered a medical condition; therefore, any surgical intervention, such as LAUP, radiofrequency volumetric tissue reduction of the palate, or palatal stiffening procedures, is considered not medically necessary. (added 3-31-2005)

These and other contracts may change without immediate revision to this online site. Therefore, a Member's specific benefit plan language should be referred to regularly.

GROUPS WITHOUT SLEEP STUDY ACCREDITATION  REQUIREMENTS
Group	Date
Federal Employee Program (FEP)	NOTE: Sleep studies may be performed at a Participating (PAR) Hospital as of 3-1-2002. AASM accreditation is not required effective 2-1-2000. Sleep studies may be performed at a Non-Participating Hospital as of 3-1-2004 (added 2-10-2004).
Sanderson Farms	Effective 1-1-2002) (added 1-10-2003)
Consolidated Catfish Co. LLC	Added 2-10-2003
Oktibbeha County Hospital (OCH)	Added 2-10-2003 Sleep study must be performed at OCH (Updated 02-01-2010)
Magnolia Management	Effective 6-1-2004, Sleep Studies are only covered if rendered by a Network provider. AASM accreditation is not required. (added 5-5-2004)
Forman Perry	Effective: 4-1-2006 NOTE: Sleep studies may be performed at any facility without prior authorization. (added 4-5-2006)
ASI dba Southeastern Healthcare Employees Medical Benefit	Studies are only covered if rendered by a Network provider. AASM accreditation is not required. Added 4-11-2012)
Ergon	Effective 01-01-2012 (Added 09-25-2012)

 

 

GROUPS THAT DO NOT COVER SLEEP STUDIES REGARDLESS OF MEDICAL NECESSITY
Group	Date
Hood Flexible Packaging Hourly	Added 7-15-2003 (Updated 02-01-2010 - removed Hood Flexible Packaging Salary)
Minact, Inc.	Added 1-7-2005

 

During the rental or purchase period of the CPAP device, the supplies and accessories are bundled with the CPAP device. Following the rental or purchase period of the device, supplies and accessories are reimbursed separately (added 9-20-2002).

The following table represents the usual maximum amount of accessories expected to be medically necessary for use with the CPAP device (added 9-20-2002):

• A7030 1 per 6 months
• A7031, A7032 2 per 1 month
• A0733 1 per 1 month
• A7034 1 per 3 months
• A7035 1 per 6 months
• A7036 1 per 6 months
• A7037 1 per 1 month
• A7038 2 per 1 month
• A7039 1 per 6 months

Either a non-heated (E0561) or heated (E0562) humidifier is covered when ordered by the treating physician for use with a covered E0601 device (added 9-20-2002).

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

6/1997: Comprehensive revision approved by MPAC

1/1999: Editorial changes

10/18/1999: Soft Palate Somnoplasty, also known as radiofrequency-mediated tongue tissue reduction or the Somnoplasty System^TM added

2/1/2000: See POLICY EXCEPTIONS

2/17/2000: Revisions in CODE REFERENCE

5/26/2000: South Central Regional Medical Center in Laurel is an accredited lab effective 5-26-2000.

6/30/2000: Jeff Anderson Regional Medical Center Meridian - added as approved Center effective 5-2-2000.

1/30/2001: Effective November 29, 2001, North Mississippi Medical Center, Sleep Disorders Laboratory accreditation approved for a period of 5 years.

2/2/2001: As of 5/1/2000, First Chemical claims for sleep study at any facility are to be processed as covered without prior authorization. Peavy Contract has a specific exclusion for treatment of or related to sleep disorders.

3/9/2001: Effective November 28, 2000, King's Daughters Hospital, Greenville, Mississippi, Sleep Disorders Laboratory accreditation approved for a period of 5 years.

3/14/2001: Policy content revised for clarity. Sleep Center vs. Lab Guidelines added to the policy (hyperlink deleted). Coverage remains the same.

Effective December 28, 1999, Neuroscience Institute of the Gulf Coast, PLLC DBA Sleep Institute of the Gulf Coast accreditation approved for a period of 5 years.

4/9/2001: St. Dominic employee group is approved to go to St. Dominic for their sleep studies - even though it's not officially an accredited facility

4/19/2001: Effective immediately: Gulf Coast Center for Sleep Apnea (formerly Southern Nights Sleep Disorders Center) at Gulf Coast Community Hospital is not accredited.

5/2001: Reviewed by MPAC; policy revised, JCAHO accreditation will not be accepted, code reference section updated, HCPCS E0452, K0193-K0194 and K0269 deleted.

5/30/2001: Baptist Memorial Hospital-Golden Triangle Sleep Lab added effective 5-2-2001

6/19/2001: HCPCS S8260 has been deleted.

7/11/2001: St. Dominic Employee Group has cancelled effective 7-01-2001.

7/13/2001: Southern Night Sleep Apnea Laboratory is accredited effective 6-27-2001 for a 5 year period.

11/1/2001: Janice L. Miles, DO, Timothy C. Hiebert, MD, Pulmonary and Sleep Medicine, Sleep Lab, 3501 Main Street, Moss Point, MS 39563 accredited effective 10-9-2001.

12/4/2001: Gulf Coast Sleep Laboratory at Gulf Coast Medical Center (Tenet) accredited; effective 9-26-2001. May MPAC policy revisions added; prior authorization deleted; Contract changes effective January 1, 2002.

1/7/2002: Sleep Disorders Center at North Mississippi Medical Center, Tupelo, Mississippi has been granted accreditation for a period of five years beginning November 29, 2000. BCBSMS and Hickory Mark Furniture added to "policy exceptions"

2/14/2002: Investigational definition added

2/28/2002: FEP PAR hospital exception added

4/18/2002: Type of Service and Place of Service deleted.

5/3/2002: Code Reference section updated, CPT codes 30520, 41599, 42820-42826 and ICD-9 Procedure codes 21.88, 28.2 and 28.3 deleted. Fourth digit 333.19 should be 333.99.

5/14/2002: Gulf Shore Sleep Disorders Center LLC accredited; effective 3-29-2002; AASM table hyperlink added

5/2002: Reviewed by MPAC; intra-oral prostheses are medically necessary when meeting criteria listed in the "Policy" section, Sources updated

6/21/2002: Hickory Mark Furniture policy exception changed to covered effective 7-1-2002. ICD-9 procedure code 31.2 4th digit added

9/20/2002: Policy Guidelines revised, Code Reference section updated, HCPCS K0531, K0532, K0533, K0534 added

12/11/2002: HCPCS S8260 added

12/20/2002: Policy Guidelines "rental and purchase" changed to "rental or purchase"

1/10/2003: Cal-Maine and Roy Anderson Corporation groups require sleep studies be performed in an accredited facility effective 8/1/02, Hickory Mark Furniture name changed to England, Inc., for Joe N. Miles & Sons, Inc. and Sanderson Farms groups, sleep studies may be performed at any facility effective 1/1/02.

2/10/2003: Policy Exceptions updated; tables added for clarity

2/27/2003: CalMaine, Roy Anderson and Joe N. Miles & Sons, Inc. effective 8-1-2002, 8-1-2002, and 1-1-2003 respectively must be performed at an accredited facility.

3/12/2003: Code Reference section updated

3/18/2003: Trilogy sleep studies may be performed at any facility added

5/8/2003: CPT code range 21193-21206, 95806-95807, 95808-95811 listed separately

5/14/2003: Gulf South Sleep Laboratory of Crosby Memorial Hospital is accredited; effective 2-25-2003

7/15/2003: Sleep Disorders Laboratory at St. Dominic-Jackson Memorial Hospital is accredited; effective 5-21-2003. Hood Flexible Packaging Hourly and Hood Flexible Packaging Salary added to "Groups That Do Not Cover Sleep Study" chart

8/7/2003: Sleep Disorders Center Greenwood Leflore Hospital is accredited; effective 6-27-2003. ICD-9 procedure codes 31.21 and 31.29 complete descriptions added, ICD-9 procedure code range 76.61-76.66 listed separately, hyperlinks added to comprehensive listing of ICD-9 diagnosis codes in "Policy" section, partial listing of ICD-9 diagnosis codes in "Code Reference" section deleted

10/28/2003: Radiofrequency Tissue Volume Reduction (RFTVR) added

11/2003: Reviewed by MPAC, no changes, "Radiofrequency Volumetric Tissue Reduction for the Treatment of Upper Airway Obstruction" remains investigational

2/10/2004: Code Reference section updated, HCPCS K0183, K0184, K0185, K0186, K0187, K0188, K0189 deleted 12/31/2002 and replaced by A codes, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039 effective date of 1-01-2003 added to "Policy Guidelines" section, HCPCS K0268, K0531, K0532, K0533, K0534 with a deletion date of 12-31-2003 deleted, "Hyoid myotomy and suspension is considered medically necessary based on the same criteria" added, CPT code 21685 added, HCPCS E0470, E0471, E0472, E0561, E0562 added covered codes

5/5/2004: Magnolia Management added to Policy Exceptions "Groups Without Sleep Study Accreditation Requirements"

5/19/2004: Code Reference section reviewed, ICD-9 diagnosis code 770.8 fifth digit (770.81, 770.82, 770.83, 770.84, 770.89) added to covered labs, ICD-9 diagnosis 786.0 deleted non-covered labs, ICD-9 diagnosis code 786.09 added to non-covered labs

6/16/2004: Ergon, Lion Oil and J. Christy added 2-10-2003 was deleted from Policy Exceptions "Groups Without Sleep Study Accreditation Requirements"

6/21/2004: People’s Bank and Trust added to Policy Exceptions "Groups Without Sleep Study Accreditation Requirements", Prior to 6-1-2003, sleep studies were covered at any facility. Effective 6-1-2003, AASM accreditation required

7/23/2004: Southern Nights Sleep Disorders Center in Hattiesburg is accredited effective 9-16-2003. City of Jackson will require accreditation by AASM effective 8-1-2004

9/1/2004: American Sleep Diagnostics, LLC is accredited effective 7-1-2004 for a 5 year period, Sleep Solutions formerly Sleep Disorders Laboratory at St. Dominic-Jackson Memorial Hospital is accredited effective 5-21-2003 for a 5 year period, Stribling Equipment, LLC/Empire Truck Sales, LLC added to Policy Exceptions “Groups Without Sleep Study Accreditation Requirements”

12/21/2004: Policy clarification of “The following services are not considered eligible for coverage:” changed to “The following services are considered investigational and not eligible for coverage:”, “Multiple sleep latency testing (MSLT) for routine screening, diagnosis or follow-up for sleep apnea.” moved to paragraph related to MSLT, LAUP and Soft Palate Somnoplasty statements deleted as this is listed under Surgical Management, hyperlink for Topographic EEG mapping inserted

1/7/2005: River Region Sleep Center is accredited effective 10/12/2004 for a 5 year period, Minact, Inc. added to "Groups That Do Not Cover Sleep Study" table

3/24/2005: Code Reference section updated, ICD-9 diagnosis code 347 under AASM centers 5^th digit with effective date of 10/1/2004 added, ICD-9 diagnosis code 781.0 under AASM centers description revised and Note: “To report services on and after 10/1/2004, see ICD-9 diagnosis code 780.58” added, ICD-9 diagnosis code 780.58 with effective date of 10/1/2004 added under AASM centers, CPT code 42145 description revised under covered codes, HCPCS A7045 with effective date of 1/1/2005 added covered codes, HCPCS E0450, E0461 description revised, CPT code 0088T with effective date of 1/1/2005 added non-covered codes

3/31/2005: Reviewed by MPAC, palatal stiffening procedures are considered investigational, Sources updated

5/13/2005: Code Reference section reviewed, CPT code 42299 added non-covered codes

6/30/2005: Howard Industries deleted from "Groups That Do Not Cover Sleep Study," effective 7/1/2005 sleep studies must be at an accredited AASM facility

7/15/2005: South Central Regional Medical Center Sleep lab upgraded to a Sleep Center renamed "South Central Regional Sleep Center at South Central Regional Medical Center" in Laurel effective 5/23/2005, accredited for a 5 year period, Delta Regional Medical Center acquisition of The King's Daughters Hospital, renamed "The King's Daughters Hospital, West Campus of Delta Regional Medical Center"

7/28/2005: Janice O. Miles, DO Pulmonary and Sleep Medicine Sleep Lab has two sites with the same name but different locations (Moss Point and Ocean Springs); the Moss Point location is no longer accredited as of 11/22/2002; the Ocean Springs location is accredited effective 11/22/2002 through 9/29/2006; Moss Point address has changed from "3501 Main Street" to "3418 Main Street"

10/25/2005: Non-Covered Code Reference section updated, deleted CPT code 76506 from non-covered codes, deleted ICD9 Procedure codes 89.14 and 89.19 from non-covered codes

11/8/2005: Code Reference section updated, ICD9 diagnosis codes effective 10/1/2005 added; 327.00-327.09, 327.10-327.19, 327.22-327.26, 327.51-327.59, V69.5; existing code 780.54 was also added

12/20/2005: Iuka Sleep Disorders Center and Premier Sleep Disorders Center added

1/17/2006: Removal of "Sleep Studies Non-Covered" for the BCBSMS Group effective 1/1/2006 (Sleep Studies were Not Covered for this Group from 1/1/2002 through 12/31/2005) Covered Sleep Studies must be done at an AASM accredited facility

3/14/2006: Coding updated. HCPCS 2006 revisions added to policy.

4/5/2006: Forman Perry added to Policy Exceptions "Groups Without Sleep Study Accreditation Requirements"

5/24/2006: Policy reviewed, no changes

5/30/2006: The Neurodiagnostic Lab and Center for Sleep Disorders and Somnus Sleep Clinic of Central MS added to policy

8/18/2006: Atrial pacing as investigational added to policy

9/18/2006: Coding updated. ICD9 2006 revisions added to policy.

10/25/2006: Pioneer Family Medical of Hamilton Sleep Laboratory added to policy

11/6/2006: Policy updated to reflect closure of FGH Sleep Center 4-24-2006. The Center for Sleep Medicine at Hattiesburg Clinic added to policy

11/20/2006: Desoto Sleep Diagnostics added to policy

12/19/2006: Costal Sleep Solutions Sleep Disorder Laboratory added to policy

4/17/2007: Accreditation effective dates updated for Sleep Disorders Center at North Mississippi Medical Center, Baptist Memorial, and Mississippi Baptist Medical Center. Baptist Memorial Hospital Golden Triangle accreditation effective date updated and moved to the accredited center list; previously listed as a lab

4/20/2007: Accreditation effective dates updated for King's Daughters Delta Regional Medical Center, University of Mississippi Medical Center, and the Sleep Institute of the Gulf Coast. King's Daughters Regional Medical Center moved to the accredited center list: previously listed as a lab

5/29/2007: Sleep Solutions, LLC dba Jackson Sleep Laboratory added to policy

5/31/2007: Southwest Regional Medical Center Diagnostic Sleep Laboratory added to policy

6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions

7/9/2007: Natchez Regional Sleep Disorders Center added to policy. Added note to indicate Southern Nights Sleep Apnea Laboratory, Gulfport, MS, is not longer accredited effective 6-27-2006.

7/19/2007: Rest Well Sleep Diagnostics, Monticello, MS, added to policy

8/24/2007: Gulf Coast Lung & Sleep Medicine Institute or Silent Night Sleep Institute, Natchez, MS, added to policy. Gulf Coast Sleep Laboratory accreditation effective date updated

9/3/2007: Northwest Mississippi Regional Medical Center (NWMRMC) Sleep Related Breathing Disorder Laboratory, Clarksdale, MS, added to policy

10/18/2007: Sleep Unlimited, Inc., Corinth, MS added to policy

11/1/2007: Integrated Sleep Solutions of Gulfport added to policy

12/27/2007: Policy section rewritten for clarity. The following groups are being removed from policy due to cancellation: First Chemical, Natcom, Preferred Care and Stanley Works

1/14/2008: Policy reviewed, no changes

2/7/2008: Indianola Sleep Clinic, LLC added to policy

4/14/2008: Magee General Hospital Sleep Lab, Magee added to policy

5/29/2008: Clarified name of sleep lab for Gulf Coast Sleep Laboratory, changed from Gulf Coast Medical Center to Biloxi Regional Medical Center

6/9/2008: HCPCS G0398, G0399, G0400 added per the 2008 quarterly updates

7/3/2008: Sweet Magnolia Moon A Sleep Center, LLC, dba Southern Neuroscience Center, PA, Hattiesburg, MS, added to policy. The sleep center was formerly named Southern Nights Sleep Disorder Center with accreditation effective date of 9/16/2003

7/17/2008: Tupelo Sleep Diagnostics, Tupelo, MS added to policy with a 6 month approval period.

8/22/2008: North Mississippi Medical Center - West Point Sleep Laboratory, West Point, MS added to policy with a 6 month approval period.

8/29/2008: Laird Hospital Sleep Lab, Philadelphia, MS; Laird Hospital Sleep Lab, Union, MS; H.C. Watkins Sleep Center, Meridian, MS 39301; Scott Regional Medical Center Sleep Lab, Forest, MS, added to policy with a 6 month approval period

9/17/2008: Sleep Unlimited Oxford, LLC dba Covenant Sleep Clinic of Oxford added to policy with a five year approval period

9/18/2008: SleepCare at Fairpark (Tupelo Neurology Clinic, PA), Oxford, MS added to policy with a 6 month approval period

12/31/2008: Code reference section updated per 2009 CPT/HCPCS codes

1/6/2009: Integrated Sleep Solutions of Ocean Springs, LLC added to policy with five year approval period

1/23/2009: Sleep Solutions of Mississippi added to policy with 6 month approval period

4/6/2009: Policy reviewed, no changes

4/20/2009: Madison Sleep Lab, LLC was added to policy with a five year approval period. Southern Sleep Diagnostics at Crossgates River Oaks Hospital in Flowood was added to the policy with a five year approval period.

5/1/2009: The Center for Sleep Medicine at Hattiesburg Clinic was updated to reflect their reaccreditation for 5 year period effective March 3, 2008.

5/27/2009: Out of state facilities are not required to be AASM Certified per BCBSMS management.

6/26/2009: Location for Integrated Sleep Solutions changed from Ocean Springs to Gautier

7/2/2009: NMMC/West point sleep lab updated to reflect accreditation for a 5 year period.

7/15/2009: Components of the Surgical Management under the Policy Statement revised for clearer understanding of policy intent

8/24/2009: Laurel Sleep Disorders Center added to policy with accreditation for 5 year period effective 4-13-09.

9/21/2009: Forest Sleep Clinic added to policy with accreditation for a 5 year period, effective 11-06-08, added statement to North Mississippi Medical Center - West Point Sleep Laboratory "This facility is the same as Clay County Medical Center"

9/30/2009: Note added to Gulf South Sleep Laboratory of Crosby Memorial Hospital

10/7/2009: Premier Sleep Disorders Center of Kosciusko add to policy with accreditation for a 5 year period, effective 09-11-09

02/01/2010: Updated the Description Section; revised Policy Section to include accredited centers and labs in Mississippi as well as the covered ICD-9 diagnosis codes for each; removed closed centers and labs; removed centers and labs that are no longer accredited; revised Policy Exceptions Section to remove specific groups without sleep study accreditation requirements and groups that do not cover sleep studies regardless of medical necessity; and revised Coding Section to delete K0553 - K0555 and 0088T, added A7027 - A7029 and revised descriptions.

02/05/2010: Revised the Policy Section to remove reference to out-of-state facilities.

06/22/2010: Policy description unchanged. Added King's Daughters Medical Center Sleep Center, Brookhaven; Hancock Medical Center, Bay Saint Louis; Grenada Diagnostic Sleep Center, LLC, Grenada; and Physicians Sleep Diagnostics, Vicksburg, as accredited providers. Coding section updated to move CPT code 95807 from non-covered to covered per the policy statement as this is an attended study procedure code

10/19/2010: Added Baptist Memorial Hospital Desoto Sleep Disorders Center as an accredited provider.

12/30/2010: Added River Region Medical Center as an accredited provider.

03/09/2011: Added new CPT codes 95800 and 95801 to the Code Reference section.

06/22/2011: Added Tri-Lakes Sleep Center as an accredited provider.

04/11/2012: Added the following as accredited providers: The Neuroscience Sleep Center (Singing River Health System), Balance Sleep Centers, Neurology and Sleep Management - Dr. Diane Ross, MD. Added ASI dba Sourtheaster Healthc are Employees Medical Benefit to the list of groups without sleep study accreditation requirements. Policy guidelines updated as follows for CPAP supplies: A7030 1 per 6 months, A0733 1 per 1 month.

05/09/2012:  Added the following to the policy statement:  1)Adenotonsillectomy may be considered medically necessary in pediatric patients with clinically significant OSA and hypertrophic tonsils. Clinically significant OSA is defined as those pediatric patients who have: AHI or RDI of at least 5 per hour, or AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems, or hyperactivity. 2) A nasal expiratory positive airway pressure (EPAP) device is considered investigational. 3) CPAP may be considered medically necessary in adult or pediatric patients with clinically significant OSA. 4) Auto-adjusting CPAP may be considered medically necessary during a 2-week trial to initiate and titrate CPAP in adult patients with clinically significant OSA. 5) Bilevel positive airway pressure or auto-adjusting CPAP may be considered medically necessary in patients with clinically significant OSA AND who have failed a prior trial of CPAP or for whom BiPAP is found to be more effective in the sleep lab.

07/12/2012:  Added Sleep Disorders Laboratory #251708 Dr. Sadeka Tamanna, MD as an accredited provider.

09/25/2012: Added Ergon to the list of groups that do not require AASM certification.

12/21/2012: Added The Seep Center of North Sunflower Medical Center as an accredited provider. Added the following new 2013 CPT codes to the Code Reference section: 95782 and 95783.

Hayes Medical Technology Directory

TEC, Vol 15, #15, 12/2000

Blue Cross Blue Shield Association policy # 2.01.18

Clark GT, et al. Effects of Anterior Mandibular Positioning on Obstructive Sleep Apnea. American Review Respiratory Distress 147: pp. 624-9, 1993.

Schmidt-Nowara, W. et al. Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea: A Review. Sleep 18 (6): pp. 501-10, 1995.

Blue Cross Blue Shield Association policy # 7.01.51

Blue Cross Blue Shield Association policy # 4.01.05

Blue Cross Blue Shield Association policy # 7.01.101

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Non-Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.

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