Sleep Disorders

POLICY NUMBER

L.2.01.415

DESCRIPTION

Obstructive sleep apnea syndrome (OSA) is characterized by repetitive episodes of upper airway obstruction that occur during sleep. Features of patients with OSA include habitual snoring, observed apneas, excessive daytime sleepiness and a body mass index (BMI) greater than 35 kg/m². Other signs and symptoms suggestive of OSA include male gender, thick neck, craniofacial or upper airway soft tissue abnormalities and unexplained hypertension.

Monitoring procedures that evaluate OSA are defined by the American Academy of Sleep Medicine (AASM) and classified as Types 1-4. Supervised polysomnography (PSG) performed with Type 1 monitors in a sleep center and unattended (unsupervised) home sleep tests (HST) performed with Type 3 monitors in the home are established methods for diagnosing OSA and are referred to as sleep studies. PSG includes sleep staging with a 4 lead electroencephalogram (EEG), an electro-oculogram (EOG) and a submental electromyogram (EMG), respiratory effort measurement, inspiratory and expiratory airflow measurement, a snoring microphone, an oxygen saturation monitor, electrocardiogram (ECG), limb EMG and body position monitor. HST includes a minimum of 4 recording channels, including oxygen saturation, respiratory movements, airflow and ECG.

Multiple sleep latency testing (MSLT) is an objective measure of the tendency to fall asleep in the absence of alerting factors which is used to evaluate patients with suspected narcolepsy. Maintenance of wakefulness testing (MWT) is an objective measure of the ability to stay awake under soporific conditions which is used to assess occupational safety. Monitoring procedures for both are defined in AASM’s “Practice Parameters for Clinical use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test”, Sleep, Vol. 28, No.1, 2005.

For patients who have failed conservative therapy, established surgical approaches may be indicated. This evidence review addresses minimally invasive surgical procedures for the treatment of OSA. They include laser-assisted uvuloplasty, tongue base suspension, radiofrequency volumetric reduction of palatal tissues and base of tongue, palatal stiffening procedures, and hypoglossal nerve stimulation.

The regulatory status of minimally invasive surgical interventions is shown below:

AHI: Apnea/Hypopnea Index; CPAP: continuous positive airway pressure; IDE: investigational device exemption; LAUP: Laser-assisted uvulopalatoplasty; OSA: obstructive sleep apnea.

POLICY

Provider Accreditation for Sleep Studies

Sleep studies must be performed in or by a Network sleep center which has met the American Academy of Sleep Medicine (AASM) Standards for Accreditation as outlined in most member's plan documents (see Policy Exceptions below). Such centers may be hospital affiliated or freestanding. Services rendered at sleep centers are generally short stays of not less than four hours and not more than twenty-four hours.

Therefore, for most members, benefits are not provided for sleep studies performed by non-accredited centers. However, evidence of accreditation does not necessarily indicate in-network affiliation. Therefore, coverage will be subject to appropriate Network benefits as outlined in the member's plan document.

Sleep centers must meet the following criteria:

1. Effective January 1999:

2. • Accreditation by the AASM, formerly known as the American Sleep Disorders Association (ASDA);

   • Interpretation of all sleep studies must be performed by a physician with Sleep Medicine Certification by the AASM or the American Board of Internal Medicine (ABIM).

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

4. AASM defined Type 1 PSG and Type 3 HST will be utilized for diagnosis of OSA.

5. PSG, HST, MSLT and MWT raw data review by a Sleep Medicine Certified physician is performed to detect artifacts and data loss.

The following Network Providers are accredited by AASM to perform in-center and home sleep testing:

Diagnosis of Obstructive Sleep Apnea

Effective 04/01/2020, prior approval is not required for sleep studies performed outside of the home setting (See Policy Exceptions). Sleep studies must be performed in the appropriate setting based on the medical necessity criteria below.

Home Sleep Studies 

A single unattended (unsupervised) home sleep study with a minimum of 4 recording channels is considered medically necessary in adults who are at high risk for OSA and have no evidence based on history and physical examination of a health condition that might alter ventilation or require alternative treatment, including central sleep apnea, heart failure, chronic pulmonary disease, obesity hypoventilation syndrome, neuromuscular disorders with sleep-related symptoms, injurious or potentially injurious parasomnias, or narcolepsy. The Policy Guidelines section defines high pretest probability.

A single unattended (unsupervised) home sleep study with a minimum of 4 recording channels is considered medically necessary as a screening tool in patients who have the benefit for and are scheduled for bariatric surgery and have no evidence based on history and physical examination of a health condition that might alter ventilation or require alternative treatment (see above). Note: Coverage of home sleep study related to bariatric surgery is subject to the Member's contract benefits and/or exclusions.

Unattended home sleep studies are considered investigational in children (<18 years of age).

Repeated unattended (unsupervised) home sleep studies with a minimum of 4 recording channels are considered medically necessary in adults under the following circumstances:

1. To assess efficacy of surgery or oral appliances or devices; OR

2. To reevaluate the diagnosis of OSA and need for continuous positive airway pressure (CPAP), eg, if there is a significant change in weight (>20%) or change in symptoms suggesting that CPAP should be retitrated or possibly discontinued.

Supervised In-Center Sleep Studies

Supervised polysomnography performed in a sleep laboratory are considered medically necessary in patients with a moderate or high pretest probability of OSA in the following situations:

1. Pediatric patients (<18 years of age); OR

2. When patients do not meet criteria for an unattended home sleep study as described above; OR

3. A previous home study failed to establish the diagnosis of OSA in a patient with a high pretest probability of OSA; OR

4. A previous home study was technically inadequate; OR

5. Failure of resolution of symptoms or recurrence of symptoms during treatment; OR

6. To reevaluate the diagnosis of OSA and need for continued CPAP, eg, if there is a significant change in weight (>20%) or change in symptoms suggesting that CPAP should be retitrated or possibly discontinued; OR

7. When testing is done to rule out other sleep disorders such as central sleep apnea, injurious or potentially injurious parasomnias, or narcolepsy; OR

8. Presence of a comorbidity that might alter ventilation or decrease the accuracy of a home sleep study, including, but not limited to heart failure, neuromuscular disease, chronic pulmonary disease, or obesity hypoventilation syndrome.

A repeated, supervised PSG performed in a sleep laboratory is considered medically necessary in patients who meet criteria for an in-laboratory PSG under the following circumstances: 

1. To initiate and titrate CPAP in adults and children with clinically significant OSA. See “Medical Management of Obstructive Sleep Apnea” for the definition of clinically significant OSA.

2. To assess efficacy of surgery (including adenotonsillectomy) or oral appliances/devices.

Note: A split-night study, in which moderate-to-severe OSA is documented during the first portion of the study using PSG, followed by CPAP during the second portion of the study, can eliminate the need for a second study to titrate CPAP (see Policy Guidelines section for criteria to perform a split-night study).

Supervised or unattended home sleep studies that do not meet the above criteria are not medically necessary.

Abbreviated daytime sleep study (PAP-NAP) is considered investigational.

Topographic EEG Mapping is considered investigational.

MSLT must be performed the day after polysomnography in a sleep center. PSG and a MSLT performed on the day after the PSG are considered medically necessary in the evaluation of suspected narcolepsy or idiopathic hypersomnia.

MSLT is considered not medically necessary for routine screening, diagnosis or follow-up for OSA.

Medical Management of Obstructive Sleep Apnea

Auto-adjusting positive airway pressure (APAP) is considered medically necessary for the titration of pressure in adults with clinically significant OSA.

CPAP is considered medically necessary in adult or pediatric patients with clinically significant OSA.

Adults with clinically significant OSA are defined as those who have:

• An Apnea/Hypopnea Index (AHI) or Respiratory Disturbance Index of at least 15 events per hour, or

• An AHI or Respiratory Disturbance Index of at least 5 events per hour in a patient with excessive daytime sleepiness, unexplained hypertension, impaired cognition, ischemic heart disease, or history of stroke.

In pediatric patients, an AHI greater than 1.5 events per hour is considered abnormal and an AHI of 10 or more may be considered severe.

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

Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) are considered medically necessary in adults with clinically significant OSA under the following conditions:

• OSA, defined by an AHI of at least 15 events per hour or an AHI of at least 5 events per hour in a patient with excessive daytime sleepiness or unexplained hypertension, AND

• A trial with CPAP has failed or is contraindicated, AND

• The device is prescribed by a treating physician, AND

• The device is custom-fitted by qualified dental personnel, AND

• There is absence of temporomandibular dysfunction or periodontal disease.

The use of CPAP, bi-level positive airway pressure, APAP, and intraoral appliances that do not meet the above criteria is considered investigational for the treatment of OSA.

The use of an abbreviated daytime sleep session for acclimation to CPAP (PAP-NAP) is considered investigational.

The use of a sleep positioning trainer with vibration is considered investigational for the treatment of positional OSA.

The use of daytime electrical stimulation of the tongue is considered investigational for the treatment of OSA.

Palate and mandible expansion devices are considered investigational for the treatment of OSA.

Nasal expiratory positive airway pressure and oral pressure therapy devices are considered investigational.

Electrosleep therapy is considered investigational.

Surgical Management of Obstructive Sleep Apnea

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.

POLICY EXCEPTIONS

POLICY GUIDELINES

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

Risk Factors for Obstructive Sleep Apnea

Although not an exclusive list, patients with all of the following symptoms are considered to be at high risk for obstructive sleep apnea (OSA):

• habitual snoring;

• observed apneas;

• excessive daytime sleepiness;

• a body mass index (BMI) greater than 35 kg/m2.

If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA (eg, age of the patient, male gender, thick neck, craniofacial or upper airway soft tissue abnormalities, unexplained hypertension) may be considered. Objective clinical prediction rules are being developed; at present, risk assessment is based primarily on clinical judgment.

Split-Night Studies

A split-night study (initial diagnostic PSG followed by CPAP titration during PSG on the same night) is an alternative to one full night of diagnostic PSG followed by a second night of titration if the following three criteria are met:

1. An AHI of at least events per hour 40 is documented during a minimum of 2 hours of diagnostic PSG. Split-night studies may sometimes be considered at an AHI between 20 and 40 events per hour, based on clinical judgment (if there are also repetitive long obstructions and major desaturations).

2. CPAP titration is carried out for more than 3 hours.

3. PSG documents that CPAP eliminates or nearly eliminates the respiratory events during rapid eye movement (REM) and non-REM sleep, including REM sleep with the patient in the supine position.

Hypoglossal Nerve Stimulation

The hypoglossal nerve (cranial nerve XII) innervates the genioglossus muscle. Stimulation of the nerve causes anterior movement and stiffening of the tongue and dilation of the pharynx. Hypoglossal nerve stimulation reduces airway collapsibility and alleviates obstruction at both the level of the soft palate and tongue base. Drug-induced sleep endoscopy (DISE) replicates sleep with an infusion of propofol. DISE will suggest either a flat, anterior-posterior collapse or complete circumferential oropharyngeal collapse. Concentric collapse decreases the success of hypoglossal nerve stimulation and is an exclusion criterion for hypoglossal nerve stimulation from the U.S. Food and Drug Administration.

Accessories and Medical Supplies

Accessories and medical supplies necessary for the effective functioning of covered Durable Medical Equipment are considered an integral part of the rental or purchase allowance.

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.

The following table represents the usual maximum amount of accessories expected to be medically necessary for use with the CPAP device:

• A7030 1 per 6 months

• A7031, A7032 2 per 1 month

• A7033 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

• A7046 1 per 12 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.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

1/1994: Approved by Medical Policy Advisory Committee (MPAC)

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™ 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 5th 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.

08/04/2014: H.C. Watkins Sleep Center, Laird Hospital Sleep Lab of Union, and Laird Hospital Sleep Lab of Philadelphia updated to reflect accreditation for a 5 year period effective August 8, 2013.

10/07/2014: Sleep Solutions (Jackson) updated to reflect accreditation for a 5 year period effective July 15, 2013.

06/24/2015: Updated the table of AASM certified sleep centers. Added link to the Orthognathic Surgery (Overbite/Underbite) medical policy for the Mandibular Maxillary Advancement (MMA) procedure. Added coverage of A7046 1 per 12 months to the Policy Guidelines. Moved covered diagnosis codes from the Policy section to the Covered Codes table for clarity purposes: 327.20 - 327.8, 327.51, 327.52, 327.53, 327.59, 347.00, 347.01, 347.10, 347.11,  780.50 -785.59, and 786.03.

07/06/2015: Corrected transposed code in Policy Guidelines section: A0733 changed to A7033.

07/30/2015: Policy statement added to clarify that all other surgical interventions and medical management procedures not stated as medically necessary are considered investigational for the treatment of OSA, including, but not limited to injection of a sclerosing agent into the palate and implantable hypoglossal nerve stimulators.

09/01/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure codes 76.61 - 76.66 as these procedures are specifically addressed in the Orthognathic Surgery (Overbite/Underbite) medical policy. ICD-9 procedure code 27.69 moved to the Investigational Codes table. Corrected ICD-9 diagnosis code 785.59 to 780.59.

12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions.

04/28/2016: Code Reference section updated to add the following diagnosis codes to the Covered Codes table: ICD-9 diagnosis codes 327.30 - 327.39, 327.40 - 327.49, 327.8 and ICD-10 diagnosis codes G47.50 - G47.59 and G47.8.

06/06/2016: Policy number L.2.01.415 added.

11/22/2016: Policy updated to add Precise Sleep Diagnosis & Treatment Center (Flowood) as an accredited provider.

12/30/2016: Code Reference section updated to add new 2017 CPT codes 0467T and 0468T. Removed deleted HCPCS codes E0450 and E0461.

02/21/2017: Policy Exceptions updated to add information regarding home/unattended sleep study testing and facility/laboratory attended polysomnography sleep studies for FEP members.

09/15/2017: Policy updated to add Merit Health Central Sleep Lab (Jackson) as an accredited provider. The following sleep centers were updated with name changes: "Natchez Community Hospital Sleep Lab" changed to "Merit Health Natchez Sleep Lab" and "Wesley Sleep Center" changed to "Merit Health Wesley Sleep Center."

12/14/2017: Policy description updated regarding monitoring procedures and testing. Policy section extensively revised to outline when home sleep studies and in-center sleep studies are medically necessary and guidelines for treatment of clinically significant OSA effective 01/01/2018. Policy updated to state that prior is required for all sleep studies performed outside of the home setting for adults (18 and older) effective 01/01/2018. Policy Guidelines updated regarding risk factors for OSA. Code Reference section updated as follows: CPT codes 95807 and 95808 were moved from covered to investigational/not medically necessary; 95806, G0398 and G0399 moved from investigational to covered effective 01/01/2018.

02/22/2018: Policy updated to add Focus Sleep Centers (Southaven), Merit Health Madison (Canton), and Sleep Unlimited, Inc. (Corinth) as accredited providers.

11/30/2018: Policy updated to remove Sleep Unlimited, Inc. (Corinth) as a Network Provider. Updated the following sleep center: "North Mississippi Medical Center" (West Point) changed to "North Mississippi Medical Center (Clay County Medical Center)." 

02/01/2019: Policy description updated regarding surgical interventions. Policy section updated to add that hypoglossal nerve stimulation may be considered medically necessary when certain conditions are met. Implantable hypoglossal nerve stimulators are considered investigational for all indications other than those listed. Policy guidelines updated regarding hypoglossal nerve stimulation. Moved 0467T and 0468T to the Covered Codes table. Added the following codes to the Covered Codes table: 0466T, 64568, 64569, 95970, 95976, 00HE0MZ, 00HE3MZ, 00HE4MZ, 00PE0MZ, 00PE3MZ, 00PE4MZ, 00PEXMZ, 00WE0MZ, 00WE3MZ, 00WE4MZ, and 00WEXMZ.

02/20/2019: Policy Exceptions updated to add the following for State Health Plan (SHP) members: Unattended home sleep studies are covered subject to medical necessity only when provided by a network sleep center which has met the AASM Standards for Accreditation. Supervised in-center sleep studies require prior approval from BCBSMS. (Effective 01/01/2019)

08/30/2019: Policy section updated to make the following change: "Pioneer Community Hospital of Aberdeen" changed to "Monroe Regional Hospital Sleep Center."

12/20/2019: Policy updated to add Comprehensive Health Specialty Clinic (Sleep Center of Natchez) as an accredited Network Provider. Code Reference section updated to add new HCPCS code K1001 effective 01/01/2020.

04/01/2020: Policy updated to state that effective 04/01/2020, prior approval is not required for sleep studies performed outside of the home setting (See Policy Exceptions). Sleep studies must be performed in the appropriate setting based on the medical necessity criteria outlined in the policy.

12/09/2020: Policy Exceptions updated to state the following for State Health Plan Participants: Effective 01/01/2021, prior approval is not required for sleep studies performed outside of the home setting. Sleep studies must be performed in the appropriate and medically necessary setting based on medical policy guidelines.

01/12/2021: Policy updated to add Merit Health Biloxi as an accredited Network Provider.

07/12/2021: Policy updated to add Magnolia Regional Hospital Sleep Center as an accredited Network Provider.

07/27/2021: Code Reference section updated to move CPT code 95800 from the Not Medically Necessary Codes table to the Medically Necessary Codes table.

08/24/2021: Policy updated to add Singing River Gulfport Sleep Center as an accredited Network Provider.

10/01/2021: Code Reference section updated to add new HCPCS code K1027, effective 10/01/2021.

12/13/2021: Code Reference section updated to add new CPT codes 42975, 64582, 64583, 64584, and HCPCS codes D9947, D9948, and D9949, effective 01/01/2022. Revised code description for CPT code 64568.

03/22/2022: Policy section updated to add statement that the use of CPAP, bi-level positive airway pressure, APAP, and intraoral appliances that do not meet the above criteria is considered investigational for the treatment of OSA. Added investigational statements for the following: 1) the use of an abbreviated daytime sleep session for acclimation to CPAP; 2) the use of a sleep positioning trainer with vibration; 3) and the use of daytime electrical stimulation of the tongue.

03/28/2022: Code Reference section updated to add new 04/01/2022 HCPCS codes K1028 and K1029.

09/30/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

12/20/2022: Code Reference section updated to add new HCPCS code D9953, effective 01/01/2023.

01/24/2023: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted CPT codes 0466T, 0467T, and 0468T.

03/31/2023: Code Reference section updated to add new HCPCS code A7049 as investigational, effective 04/01/2023.

09/26/2023: Code Reference section updated to add new HCPCS codes E0490 and E0491. Revised the code description for HCPCS code K1028. Effective 10/01/2023.

12/21/2023: Code Reference section updated to add new 2024 HCPCS codes D9954, D9955, E0492, E0493, and E0530, effective 01/01/2024.

03/13/2024: Policy updated to add Baptist Memorial Hospital - Union County as an accredited Network Provider. Policy Exceptions updated to remove the following groups: State Health Plan (State and School Employees), Sanderson Farms, Ergon, Hood Flexible Packaging Hourly, and Minact, Inc. Revised exception for FEP Standard and Basic Group to state the following: Prior approval is required for sleep studies performed in a provider’s office, sleep center, clinic, any type of outpatient center, or any location other than your home.

03/27/2024: Code Reference section updated to add new HCPCS code K1037, effective 04/01/2024.

08/23/2024: Policy updated to add Memorial Sleep Center Gulfport as an accredited Network Provider.

03/26/2025: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted HCPCS codes K1001, K1028, and K1029.

09/23/2025: Policy section updated to revise medically necessary criteria for hypoglossal nerve stimulation. Policy Guidelines updated.

SOURCE(S)

1. Blue Cross Blue Shield Association policy # 2.01.18

2. Blue Cross Blue Shield Association policy # 7.01.51

3. Blue Cross Blue Shield Association policy # 4.01.05

4. Blue Cross Blue Shield Association policy # 7.01.101

5. “Practice Parameters for Clinical use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test”, American Association of Sleep Medicine, Sleep, Vol. 28, No.1, 2005.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

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

Medically Necessary Codes

Investigational / Not Medically Necessary Codes

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