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Sleep studies consist of selected diagnostic and therapeutic services provided for sleep-related disorders. This policy addresses sleep studies in patients who are 18 years of age or older. Sleep studies for patients under the age of 18 years are addressed in a separate policy: Sleep Studies/Polysomnograms in Children and Adolescents, II-128.
Definitions
Apnea Hypopnea Index (AHI) equals the average number of episodes of apnea and/or hypopnea per hour of sleep.
Epworth Sleepiness Scale (ESS): This is a short questionnaire designed to be completed by patients. The purpose of the scale is to subjectively assess severity of daytime sleepiness. The maximum score is 24. A score of 10 or lower is considered normal.
Multiple Sleep Latency Test (MSLT) consists of physiological measurements of sleep during a series of 20 minute naps at two-hour intervals performed four to five times in an eight-hour period.
Maintenance of Wakefulness Test (MWT) measures the ability to stay awake in a sleep-inducing environment and is used to assess occupational safety.
Nap Testing: Abbreviated daytime sleep studies have been proposed for a number of conditions. One device, the PAP-NAP, is intended to acclimate patients with complex insomnia to positive airway pressure (PAP) devices. The device uses PAP therapy along with a type 3 monitor (described below) during 1-2 hour daytime naps with the intention of transitioning patients to nighttime PAP. Patients who meet certain thresholds are referred to split-night PSG for full sleep studies and PAP titration if indicated.
Narcolepsy: Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. It is currently believed to be caused by a deficiency in hypocretin-producing neurons in the lateral hypothalamus. It is estimated that narcolepsy affects approximately 1 in 2000 people in the U.S. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the day. These sudden sleep attacks may occur during any type of activity at any time of the day. Narcolepsy is also characterized by cataplexy, hypnagogic hallucinations and/or sleep paralysis. Narcolepsy and OSA can co-occur. Therefore, testing for OSA is important in the workup of narcolepsy.
Obesity hypoventilation syndrome may coexist with obstructive sleep apnea (OSA) and other sleep-disordered breathing patterns. It is generally defined as awake hypoventilation (arterial carbon dioxide tension[PaC02] greater than 45 mmHg in a patient with a body mass index greater than 30 kg/m2 ) without comorbid conditions that may influence breathing function such as pulmonary or neuromuscular disease.
Obstructive sleep apnea (OSA): A diagnosis of OSA syndrome is accepted when an adult patient has an AHI greater than 5 and symptoms of excessive daytime sleepiness or hypertension. It is estimated that approximately 20% of adults have at least mild OSA, defined as an AHI or respiratory disturbance (RDI) of 5-15 respiratory events per hour of sleep. In adults, an AHI or RDI equal to or greater than 15 is typically considered moderate OSA, while an AHI or RDI greater than 30 is considered severe OSA. An estimated 7% of adults have moderate or severe OSA.
Parasomnia: Disruptive sleep disorders that occur during arousals from rapid eye movement (REM) sleep or partial arousals from non-REM sleep. Parasomnias include but are not limited to confusional arousals, sleep walking, sleep tremors, nightmare disorder, sleep paralysis, and sleep related eating disorder.
Polysomnography (PSG) is a detailed overnight sleep study that takes place under supervision of a medical professional in a facility-based sleep center. PSG includes recording of electrographic variables (electroencephalogram [EEG], electrooculogram [EOG], and submental electromyogram [EMG]) that permit identification of sleep and its various stages; ventilatory variables that permit the identification of apneas and their classification as central or obstructive; arterial oxygen saturation by ear or finger oximetry; and heart rate. Other parameters of sleep, such as extremity muscle activity, continuous blood pressure monitoring, and body position changes, may be recorded as needed. PSG is distinguished from other sleep studies by the inclusion of EEG, EOG, and EMG for the determination of sleep stage. Full night PSG refers to testing that takes place throughout the night. Split-night PSG is defined below.
Positive Airway Pressure Devices
Respiratory Disturbance Index (RDI) may be defined as the number of apneas, hypopneas, and respiratory event related arousals (RERAs) per hour of sleep. It may be referred to along with or instead of AHI particularly in unattended sleep studies.
Split-night PSG: A split-night study is one in which the initial diagnostic PSG is followed by CPAP titration on the same night. A split-night study followed by CPAP during the second half of the study may eliminate the need for a second study to titrate CPAP.
Unattended Portable Sleep Studies have been developed to evaluate sleep disorders in an effort to substitute for the more costly facility-based PSG. Generally, these studies are not supervised by a technician during testing. Monitors are classified into four different categories based on the data recorded.
With the development of additional protocols for assessing OSA, the American Academy of Sleep Medicine (AASM) guidelines recommend that equipment used outside the setting of a sleep center must provide an RDI based on measures that approximate an AHI based on full PSG. Equipment must also simultaneously record oxygen saturation, heart rate, airflow and respiratory effort.
For applicable clinical criteria, see the following eviCore clinical guideline:
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Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.