National Medical Policy Subject:

Obstructive Sleep Apnea in Children

Policy Number:

NMP398

Effective Date*: January 2008 Updated:

December 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document

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X

Source National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other None

Reference/Website Link

Use Health Net Policy

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Current Policy Statement: Health Net, Inc. considers any of the following medically necessary: 1. Overnight polysomnography (PSG) in a sleep lab setting for children for the diagnosis of any of the following conditions: 

Sleep related breathing disorders, such as obstructive sleep apnea, upper airway resistance syndrome; or



Narcolepsy or idiopathic hypersomnia (generally would be performed in conjunction with a multiple sleep latency test); or



Congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorders or chest wall deformities



Nocturnal seizure activity; or

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REM behavior disorder (rare in childhood); or

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Mild OSAS preoperatively following adenotonsillectomy when there is residual symptoms of OSAS.



Following adenotonsillectomy to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway, and neurologic disorders (e.g., Down syndrome, Prader-Willi syndrome, and myelomeningocele).

2. Indications for overnight polysomnography in a sleep lab setting for children where obstructive sleep-disordered breathing is suspected, include any of the following: 

Habitual (nightly) snoring associated with any of the following:  Restless or disturbed sleep; or  Behavioral disturbance, or learning disorders including deterioration in academic performance, hyperactivity, or attention deficit disorder; or  Unexplained enuresis at an inappropriate age; or  Frequent awakenings; or  Failure to thrive or growth impairment; or



Witnessed apnea for greater than 2 respiratory cycle times (inspiration and expiration); or



Excessive daytime somnolence, or altered mental status unexplained by other conditions or etiologies; or



Polycythemia unexplained by other conditions or etiologies; or



Cor pulmonale unexplained by other conditions or etiologies; or



Hypertrophy of tonsils and adenoids associated with noisy daytime respirations where surgical removal poses a significant risk and would be avoided in the absence of sleep disordered breathing; or

3. Polysomnography in selected cases of primary sleep apnea of infancy. (when other medical disorders have been ruled out) Obstructive Sleep Apnea in Children Dec 15

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4. Polysomnography when there is clinical evidence of a sleep related breathing disorder in infants who have experienced an apparent life-threatening event (ALTE). 5. Tonsillectomy and adenoidectomy for treatment of obstructive sleep apnea in children with adenotonsillar hypertrophy. 6. Repeat overnight polysomnography in a sleep lab setting for children is considered medically necessary in any of the following circumstances: 

Initial polysomnography is inadequate or non-diagnostic and the accompanying caregiver reports that the child's sleep and breathing patterns during the testing were not representative of the child's sleep at home; or



For positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome.



A child with previously diagnosed and treated obstructive sleep apnea who continues to exhibit persistent snoring or other symptoms of sleep disordered breathing.



To periodically re-evaluate the appropriateness of continuous positive airway pressure (CPAP) setting based on the child's growth pattern or the presence of recurrent symptoms while on CPAP; or



If obesity was a major contributing factor and significant weight loss has been achieved, repeat testing may be indicated to determine the need for continued therapy.

Although there are no widely accepted, standardized guidelines or diagnostic criteria for classic obstructive sleep apnea in children, diagnosis of OSA can be made when the following are met:

Polysomnographic Criteria for OSA in Adults and Children Criteria Apnea-hypopnea index* Minimum oxygen saturation (%)

Adults

Children (1 to 12 years old)

>5

>1

< 85%

< 92%

* The apnea-hypopnea index is the average number of apneas and hypopneas per hour of sleep

CPAP is indicated when all of the following criteria are met: 

OSA diagnosis has been established by PSG; and



Adenotonsillectomy has been unsuccessful or is contraindicated, or when definitive surgery is indicated but must await complete dental and facial development.

Health Net, Inc. considers any of the following not medically necessary, because the peer- reviewed medical literature does not support their use:

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

Repeat polysomnography in the follow-up of patients with obstructive sleep apnea treated with CPAP when symptoms attributable to sleep apnea have resolved; or



Polysomnography in children for any of the following:  Sleep walking or night terrors; or  Routine evaluation of adenotonsillar hypertrophy alone without other clinical signs or symptoms suggestive of obstructive sleep disordered breathing; or  Routine follow-up for children whose symptoms have resolved post-adenotonsillectomy.

Health Net, Inc. considers home home/portable sleep studies for the diagnosis of OSA in children (less than 18 years of age) investigational. Limited portable studies, or studies in the home, are not sufficient to exclude OSA in a child with suggestive symptoms, nor can they reliably assess the severity of the disorder which is important in planning treatment. Overnight polysomnography remains the diagnostic "gold standard” in children with OSA.

Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets.

ICD-9 Codes 307.40-307.49 327.00-327.8 347.00-347.11 518.81 780.50-780.59 786.09

Specific disorders of sleep of non-organic origin Organic sleep disorders Cataplexy and narcolepsy Respiratory failure Sleep disturbances (sleep apnea code range) Other dyspnea and respiratory abnormalities

ICD-10 Codes F51.0-F51.09 G47.0-G47.9 J96.0-J96.22 R06.00-R06.9

Sleep disorders not due to a substance or known physiological condition Sleep disorders Respiratory failure, not elsewhere classified Abnormalities of breathing

CPT Codes 42820 42821 42825 42826 42830 42831 94660 95782

Adenotonsillectomy < age 12 Adenotonsillectomy > age 12 Tonsillectomy < age 12 Tonsillectomy > age 12 Adenoidectomy < age 12 Adenoidectomy > age 12 Continuous positive airway pressure ventilation (CPAP), initiation and management Polysomnograpy, younger than 6 years, sleep staging with 4 or

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95783

95805 95806 95807 95808 95810 95811

more additional parameters of sleep, attended by a technologist Polysomnograpy, younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness Sleep study, simultaneous recording of ventilation, respiratory effort, ECG, or heart rate, and oxygen saturation, unattended by a technologist Sleep study, simultaneous recording of ventilation, respiratory effort, ECG, or heart rate, and oxygen saturation, attended by a technologist Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist Polysomnograpy, age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist Polysomnograpy, age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

HCPCS Codes A7030-A7046 E0470

E0471

E0472

E0561 E0562 E0601

Accessories/supplies, code range for positive pressure airway devices (code range) Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) Humidifier, nonheated, used with positive airway pressure device Humidifier, heated, used with positive airway pressure device Continuous airway pressure (CPAP) device

Scientific Rationale – Update December 2015 Toon et al (2015) compared two commercial sleep devices, an accelerometer worn as a wristband (UP) and a smartphone application (MotionX 24/7), against polysomnography (PSG) and actigraphy (Actiwatch2) in a clinical pediatric sample. Children and adolescents (N = 78, 65% male, mean age 8.4±4.0 y) with suspected sleep disordered breathing (SDB), simultaneously wore an actiwatch, a commercial wrist-based device and had a smartphone with a sleep application activated placed near their right shoulder, during their diagnostic PSG. Outcome variables were sleep onset latency (SOL), total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE). Paired comparisons were made between PSG, actigraphy, UP, and MotionX 24/7. Epoch-by-epoch comparisons determined sensitivity, specificity, and accuracy between PSG, actigraphy, and UP. Bland-Altman plots determined level of agreement. Differences in bias between SDB severity and developmental age were assessed. No differences in mean TST, WASO, or SE between PSG and actigraphy or Obstructive Sleep Apnea in Children Dec 15

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PSG and UP were found. Actigraphy overestimated SOL (21 min). MotionX 24/7 underestimated SOL (12 min) and WASO (63 min), and overestimated TST (106 min) and SE (17%). UP showed good sensitivity (0.92) and accuracy (0.86) but poor specificity (0.66) when compared to PSG. Bland-Altman plots showed similar levels of bias in both actigraphy and UP. Bias did not differ by SDB severity, however was affected by age. The authors concluded when compared to PSG, UP was analogous to Actiwatch2 and may have some clinical utility in children with sleep disordered breathing. MotionX 24/7 did not accurately reflect sleep or wake and should be used with caution. Dehaan et al (2015) described clinical PSG results, sleep physicians' diagnosis, and treatment of sleep disorder breathing in children less than 2 years of age in a retrospective clinical chart review at a pediatric tertiary care center, pediatric sleep laboratory. Children less than 2 years of age who underwent clinical PSG over a 3year period. PSG results and physician interpretations were identified for inclusions. Children were excluded if either PSG results or physician interpretations were unavailable for review. Infants were classified in three age groups for comparison: 12 months. Matched records were available for 233 PSGs undertaken at a mean age 11.1±7.0 months; 31% were