Portable MSLT performed in the home setting.For evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia), including, but not limited to, insomnia,Ĭircadian rhythm disorders, and Shift Work Sleep Disorder (SWSD) OR.For routine follow-up after treatment of sleep related disorders OR.When performed for routine diagnosis of obstructive sleep apnea OR.MSLT is considered not medically necessary in the following four situations: AHI or RDI between 5 and 14 (requires one) Under individual consideration APAP may be allowed in selective patients in lieu of repeated CPAP titration when the attending sleep center physician indicates that, in his/her opinion the member would be a suitable candidate for this approach based upon member’s knowledge, behavior, and health status.ĭiagnosis of OSA with abnormal Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)Ģ.Patients who do not have sleep apnea, but who have restrictive lung disease and documented desaturation at night, requiring nocturnal ventilation.Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than five and any of the following associated symptoms:.Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than fifteen, or.AHI or RDI greater than or equal to 15 events per hour, orĬPAP (E0601) may be considered medically necessary for:.Clinically significant OSA in this case is defined as those patients who have: Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA), may be considered medically necessary in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP. AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.Apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour, or.Uvulopalatopharyngoplasty (UPPP) may be considered medically necessary for the treatment of clinically significant obstructive sleep apnea syndrome (OSA) in appropriately selected adult patients who have not responded to or do not tolerate nasal continuous positive airway pressure (CPAP). Surgical Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS)
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