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					                             Local Coverage Determination

CPT Code/Search Topic
“Sleep Apnea”

LMRP/LCD ID
L4670

LMRP/LCD Title
Treatment of Obstructive Sleep Apnea (OSA)

         Indications and Limitations of Coverage and/or Medical Necessity


Sleep Apnea with respiratory dysfunction resulting in cessation or near cessation of
respiration for a minimum of 10 seconds. (The Greek word “apnea” literally means
“without breath.”) These cessations of breathing may be due to either an occlusion of the
airway (obstructive sleep apnea), absence of respiratory effort (central sleep apnea), or a
combination of these factors (mixed sleep apnea). Central sleep apnea is a relatively rare
entity. Obstructive sleep apnea, the most common type, is caused by one of the
following: (1) reduced upper airway caliber due to obesity, adenotonsillar hypertrophy,
mandibular deficiency, macroglossia, or upper airway tumor; (2) excessive pressure
across the collapsible segment of the upper airway; or (3) activity of the muscles of the
upper airway insufficient to maintain patency. Despite the difference in the root cause of
each type, in all three, people with untreated sleep apnea stop breathing repeatedly during
their sleep, sometimes hundreds of times during the night and often for a minute or
longer.

The most common nocturnal (during sleep) symptoms of sleep apnea are severe snoring
and abnormal motor activity (i.e., patients flail extremities). Symptoms while awake are
excessive daytime sleepiness due to sleep disruption and cognitive impairment, including
poor memory and personality changes.

Polysomnography is the test of choice to diagnose sleep apnea and is diagnostic if more
than 5 observed apneas or hypopneas occur per hour of sleep during at least 6 hours of
sleep. Normally, the polysomnography measurements used to diagnose sleep apnea are:
the electrophysiologic indices of sleep staging (EEG, EOG, EMG); electromechanical
indices contrasting respiratory effort with actual ventilation (chest and/or abdomen
movement; airflow at the nose and mouth); and consequences of apneic events, including
electrocardiograms and pulse oximetry. Ordinarily, sleep apnea can be diagnosed by a
single polysomnogram.

Treatment options for OSA include weight reduction, sleep position training,
medications, oral appliances designed to keep the tongue and jaw forward, nasal
continuous positive airway pressure (CPAP), and a variety of surgical procedures.
Nasal continuous positive airway pressure is the recommended therapy for patients with
moderate to severe OSA. Nasal CPAP is a non-invasive technique that prevents upper
airway occlusion by splinting the pharyngeal airway with low levels of positive pressure
through the nares via a nasal mask. The purpose is to prevent the collapse of the
oropharyngeal walls and the obstruction of airflow during sleep, which occurs in OSA.

Surgical treatments for OSA are used to achieve upper airway reconstruction and can be
divided into phase I and phase II procedures. Phase I surgeries advance the tongue off the
back of the throat by advancing the front of the jaw and consist of one, or a combination
of a variety of procedures, including uvulopalatoplasty (UPPP), inferior sagittal
mandibular osteotomy, and genioglossus advancement, with or without hyoid suspension.
Phase II surgery achieves advancement of both the maxilla and mandible and is called
maxillomandibular osteotomy and advancement (MMA).

Tracheostomy remains the surgical approach with the greatest effectiveness since it
bypasses all areas of obstruction in the nasal, palatal, lingual and pharyngeal areas.
However, tracheostomy is associated with significant morbidity. This operation should be
considered when other options do not exist, have failed or are refused, or when this
operation is deemed necessary by clinical urgency.

Indications
Sleep apnea must be diagnosed by polysomnography. Treatment for sleep apnea is
generally recommended for any patient with an apnea index (number of apneas per hour
of sleep) greater than 20 or if patients with fewer apneic episodes are symptomatic
(excessive daytime sleepiness, snoring, etc.).

Oral Appliances for OSA
A non-surgical treatment for OSA involves the use of intraoral orthotics. These
appliances are indicated for use in patients with primary snoring or mild OSA who do not
respond to or are not appropriate candidates for treatment with behavioral measures such
as weight loss or sleep position changes. Patients with moderate to severe OSA should
have an initial trial of nasal CPAP as greater effectiveness has been shown with CPAP
than with oral appliances. If patients with moderate to severe OSA are intolerant of or
refuse treatment with CPAP, intraoral orthotics may be considered. Oral appliances may
also be indicated for patients who refuse or are not candidates for surgical treatments.

Measurement for and instruction on the use of these devices may be performed by a
dentist or physician, and therefore be eligible for Medicare Part B reimbursement, but the
devices themselves are considered to be durable medical equipment and should be billed
to the Durable Medical Equipment Regional Carrier (DMERC).

Continuous Positive Airway Pressure (CPAP)
The use of CPAP devices are covered under Medicare when ordered and prescribed by
the licensed treating physician to be used in adult patients with OSA if either of the
following criteria using the Apnea-Hypopnea Index (AHI) are met:
1. AHI greater than or equal to 15 events per hour, or
2. AHI greater than or equal to 5 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.

The AHI (Apnea -Hypopnea Index) is equal to the average number of episodes of apnea
and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by
polysomnography using actual recorded hours of sleep (i.e., the AHI may not be
extrapolated or projected).

Sleep Apnea is defined as a cessation or near cessation of airflow for at least 10 seconds
during sleep. Hypopnea is defined as an abnormal respiratory event lasting at least 10
seconds with at least a 30% reduction in thoracoabdominal movement or airflow as
compared to baseline, or with at least a 4% oxygen desaturation.

Measurement for and instruction on the use of CPAP may be performed by a physician
and therefore be eligible for Medicare Part B reimbursement, but the devices themselves
are considered to be durable medical equipment and should be billed to the Durable
Medical Equipment Regional Carrier (DMERC).

Surgery
Surgical treatments for OSA will be considered for coverage by Medicare if all of the
following conditions are met:


      A diagnosis of sleep apnea has been made by a monitored polysomnogram.
      The severity of OSA has been determined.
      Conservative treatments (e.g., weight loss, sleep training, nasal CPAP) alone
       appropriate to the severity of the OSA have been unsuccessful, suboptimal or
       inappropriate.
      There is an underlying specific surgically correctable abnormality that is causing
       the sleep apnea.

Uvulopalatopharyngoplasty (UPPP)
UPPP is an accepted means of surgical treatment for OSA, but is often not curative. This
procedure, with or without a tonsillectomy, may be appropriate for patients with
narrowing or collapse in the retropalatal region.

UPPP is covered for those patients who have all of the following:

1. Obstructive sleep apnea diagnosed (prior to any proposed surgery) in a sleep disorders
laboratory;
2. An apnea-hypopnea index as noted above;
3. Failed to respond to continuous positive airway pressure therapy or cannot tolerate
CPAP or other appropriate non-invasive treatment;
4. Been counseled by a physician, with recognized experience in sleep disorders, about
the potential benefits and risks of the surgery; and
5. Physician opinion of retropalatal or combination retropalatal/retrolingual obstruction as
the cause of the obstructive sleep apnea.

Genioglossus Advancement
Genioglossus advancement with or without hyoid suspension, when not performed in
conjunction with other covered procedures, is considered investigational at this time, and
not covered by Medicare.

Maxillomandibular Advancement (MMA)
MMA is a procedure developed for those patients with retrolingual obstruction, or those
patients with retropalatal and retrolingual obstruction who have not responded to CPAP
or to Phase I surgeries.

Maxillomandibular Advancement is covered for those patients who have all of the
following:

1. Obstructive sleep apnea diagnosed (prior to any proposed surgery) in a sleep disorders
laboratory
2. An apnea-hypopnea index as noted above.
3. Failed to respond to continuous positive airway pressure therapy or cannot tolerate
CPAP or other appropriate non-invasive treatment;
4. Been counseled by a physician, with recognized experience in sleep disorders, about
the potential benefits and risks of the surgery; and
5. Evidence of retrolingual and/or retropalatal obstruction as the cause of the obstructive
sleep apnea, or previous failure of UPPP to correct the obstructive sleep apnea.

Regarding the MMA operation:


      Separate repositioning of teeth would not be necessary except under unusual
       circumstances; but if necessary the dental work would be covered.
      Application of an interdental fixation device is occasionally necessary, and is a
       covered service (see documentation requirements).

Tracheostomy
Tracheostomy is covered for obstructive sleep apnea that is, in the judgment of the
attending physician, unresponsive to other means of treatment or in cases where other
means of treatment would be ineffective or not indicated.

Laser-Assisted Uvulopalatoplasty (LAUP)
Laser-assisted uvulopalatoplasty (LAUP) is a similar procedure to UPPP, in which part of
the uvula and associated soft palate tissues are excised. The tonsils and lateral pharyngeal
wall tissues are not removed. LAUP is performed sequentially over several outpatient
procedures under local anesthesia. This service is covered for the same indications as
listed above under UPPP. The medical record documentation must support the indications
and must be submitted with all claims for this service. Claims for LAUP performed
solely for the treatment of socially disruptive snoring will be denied.

Other surgical procedures
When OSA is caused by specific anatomic abnormalities of the upper airway (such as,
but not limited to, enlarged tonsils, enlarged adenoids or an enlarged tongue), surgery to
correct these abnormalities is covered if medically necessary based on adequate
documentation in the medical records supporting the significant contributions of these
abnormalities to OSA.

Radiofrequency ablation may be used to reduce and tighten excess tissues of the soft
palate, uvula and tongue base (SomnoplastyTM) or nasal passages and soft palate
(coblation or coblation channeling). These procedures are performed in an outpatient
setting under local anesthesia. These procedures are not covered for obstructive sleep
apnea as current literature does not support their efficacy and applicability.

Limitations
Services performed for diagnoses not included in the “ICD-9 Codes That Support
Medical Necessity” section of this policy will be denied.

Claims for genioglossus advancement surgery, when not performed in conjunction with
other allowed procedures, will be denied.

Claims for laser-assisted uvulopalatoplasty performed solely for the treatment of socially
disruptive snoring will be denied.



Coverage Topic
Surgical Services
Diagnostic Tests and X-Rays



CPT/HCPCS Codes


 21110 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR
       CONDITIONS OTHER THAN FRACTURE OR DISLOCATION,
       INCLUDES REMOVAL
 21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT
       MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE
       SYNDROME), WITHOUT BONE GRAFT
 21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT
       MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS
       (INCLUDES OBTAINING AUTOGRAFTS)
 21196 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY,
       SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION
 30999 UNLISTED PROCEDURE, NOSE
 31600 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE);
 42145 PALATOPHARYNGOPLASTY (EG,
       UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)
 42299 UNLISTED PROCEDURE, PALATE, UVULA
 94660 CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP),
       INITIATION AND MANAGEMENT

These codes were previously Not Otherwise Classified (NOC) codes. They have been
moved to Field 24 (CPT/HCPCS Codes) on 10/9/2003.
 30999      UNLISTED PROCEDURE, NOSE
 42299     UNLISTED PROCEDURE, PALATE, UVULA




ICD-9 Codes that Support Medical Necessity
(Applicable to procedure codes 42145 and 94660)
 780.51       INSOMNIA WITH SLEEP APNEA
 780.53     HYPERSOMNIA WITH SLEEP APNEA
 780.57     OTHER AND UNSPECIFIED SLEEP APNEA