Obstructive Sleep Apnea Diagnosis and Treatment Policy by mikesanye

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									       Obstructive Sleep Apnea, Diagnosis and Treatment

    Policy
    Bluegrass Family Health covers the diagnosis and treatment of obstructive airway
    disease according to the criteria outlined below.

    Background

•   Severe sleep apnea may cause morbidity and mortality through the development
    of hypertension and heart failure, as well as secondary mortality and morbidity
    due to accidents.
•   Over the last decade, the diagnosis of milder forms of obstructive sleep apnea
    (OSA) has increased the estimated prevalence of sleep-related disorders in the
    general population. However, much is controversial regarding the clinical
    significance of these milder forms.

    Scope

•   This guideline focuses on the diagnosis and treatment of obstructive sleep apnea
    (OSA) and the upper airway resistance syndrome (UARS) in adults.
•   Snoring will be discussed only as it relates to the primary focus of the guideline.
•   Narcolepsy and restless leg syndrome will not be discussed.
•   Pediatric sleep disturbances are not discussed.


    Diagnosis
    ICD-9 Diagnosis: 780.51, 780.53, 780.57

    Key Issues
    A thorough history usually can make the diagnosis of OSA

    History

•   Assess patient's bedtime and awakening habits
•   Assess use of sedatives and alcohol
•   Assess for the severity and pattern of symptoms of OSA
       o Major symptoms
                § Snoring
                       § More frequent occurrences and increased intensity are
                           associated with an increased likelihood and severity of
                           OSA
                § Excessive daytime sleepiness (EDS)



                                                                                          1
                          §   Sleep-related driving impairment is highly suggestive of
                              OSA.
                          § EDS (typically falling asleep while watching television or
                              reading) does not predict sleep apnea.
                  § Witnessed apnea and choking episodes strongly suggests OSA
          o Screening questionnaires and checklists may help document essential
              history in a busy office practice.
                  § Snoring, observed choking or apnea spells, and sleep-related
                      driving impairment were best predictors of sleep apnea identified
                      on sleep questionnaires. Adding the presence of male gender and
                      increased BMI increased the predictive ability of these factors by
                      10%.
                  § Epworth Sleepiness Scale (ESS) is not very useful for the
                      identification of OSA.
          o Symptoms that may be sequelae of or worsened by sleep disordered
              breathing:
                  § Headaches upon awakening
                  § Heartburn and reflux
                  § Nocturia or nocturnal enuresis
                  § Night sweats
                  § Mood disorder
                  § Impaired cognition
                  § Fibromyalgia-like symptoms
          o Significant comorbidities possibly related to sleep apnea:
                  § Hypertension
                  § Cardiovascular and cerebrovascular disease
                  § Heart failure
                  § Obesity
   •   Upper airway resistance syndrome (UARS)
          o The clinical significance of this syndrome is not yet clear.
          o Presence of the following factors suggests UARS:
                  § Excessive daytime sleepiness is most common symptom.
                  § Patients younger than OSA patients
                  § Patients typically not obese (BMI less than 25)
                  § Hypertension often present

Physical Findings

   •   Examine for obesity.
   •   Check for elevated BP.
   •   Check for signs of heart failure;.
   •   Perform an oropharyngeal examination.
           o Possible findings are redundant pharyngeal tissue, small oropharyngeal
              airway, deviated septum, enlarged tonsils, or enlarged tongue.
           o No abnormality seen in half the cases




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Clinical Indications for Referral

   •   Indications for sleep consult
           o Presence of one or more major symptoms of OSA
           o Hypertension, if resistant to therapy and sleep apnea is a possible
               explanation
           o Request for palatal surgery for snoring
   •   Preoperative screening of patients with sleep apnea before general surgical
       procedures is needed only if OSA is severe or consult is requested by
       anesthesiologist



Diagnostic Testing

   •   Sleep study or polysomnography (PSG)
           o The most accurate diagnostic test, and indicated for all patients in whom
               sleep apnea is suspected

       Based on the 1997 American Sleep Disorders Association (ASDA) indications for
       Polysomnography Task Force Report, Bluegrass Family Health will cover ANY
       of the following diagnostic techniques if indications above are met:

          1. Standard diagnostic full-channel nocturnal polysomnography (NPSG)
             when performed in a healthcare facility in patients with symptoms
             suggestive of obstructive sleep apnea (OSA);
          2. Portable standard diagnostic NPSG performed in the patient's home is
             covered only when a trained technologist is in attendance and ANY of the
             following criteria are met:

                  •   For follow-up of patients to reassess therapy when a
                      diagnosis has been established by standard
                      polysomnography, and therapy has been initiated; OR
                  •   For patients who are unable to be studied in a sleep lab
                      (e.g., nonambulatory patients who cannot be safely moved);
                      OR
                  •   For patients with severe clinical symptoms indicative of
                      OSA, when initial treatment is urgent, and standard
                      polysomnography is not available;

          3. Split-night study NPSG in which the final portion of the NPSG is used to
             titrate continuous positive airway pressure (CPAP);

       Note: On occasion, an additional full-night CPAP titration NPSG may be required
       and covered if the split-night study did not allow for the abolishment of the vast




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majority of obstructive respiratory events or prescribed CPAP treatment does not
control clinical symptoms.

   4. Limited-channel diagnostic NPSG for patients with a high pretest
      probability of OSA based on validated screening algorithms.

Repeat sleep studies may be covered up to twice a year for ANY of the following
indications:

   1. To determine whether positive airway pressure treatment (i.e., CPAP,
      bilevel positive airway pressure (BiPAP), demand positive airway
      pressure (DPAP), variable positive airway pressure (VPAP), or auto-
      titrating positive airway pressure (AutoPAP)) continues to be effective;
      OR
   2. To determine whether positive airway pressure treatment settings need to
      be changed; OR
   3. To determine whether continued treatment with positive airway pressure
      treatment is necessary; OR
   4. To assess treatment response after upper airway surgical procedures and
      after initial treatment with oral appliances.

Bluegrass Family Health does not cover ANY of the following diagnostic
techniques in patients with symptoms suggestive of OSA:

   1. Nocturnal pulse oximetry alone as a case finding or screening method to
      rule out OSA. Pulse oximetry when used alone has an inadequate negative
      predictive value (i.e., all patients with symptoms suggestive of OSA
      would require a polysomnogram regardless of whether the pulse oximetry
      was positive or negative).
   2. Limited-channel NPSG for distinguishing sleep from wake or determining
      sleep stage.
   3. The Madaus electronic sleep apnea monitor (MESAM) device.
   4. The static charge sensitive bed.
   5. Actigraphy.
      This technique has not been validated as a method of diagnosing OSA
      although it may be a useful adjunct to other procedures in the evaluation
      of sleep disorders.
   6. TSH is indicated only if there are symptoms and signs of hypothyroidism

   Note: Patients should be re-evaluated after 2 to 3 months to establish their
   continued need for noninvasive positive pressure ventilation. For continued
   coverage beyond 3 months, patients should be compliantly using the device
   (an average of 4 hours per 24-hour period; an average less than 4 hrs may
   meet criteria only if documentation is provided indicating a medical reason for
   non-usage), and the patient must be demonstrably benefiting from its use.




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              Definitions

              Apnea: Cessation of airflow > 10 seconds documented by PSG

              Hypopnea: Reduction in airflow > 10 seconds associated with fall in
              oxygen saturation and an arousal from sleep documented on PSG



Clinical Indications for Imaging

   •   Cephalometry
          o Not indicated for the routine diagnosis of OSA



Treatment

Key Issues

   •   Treatments for upper airway resistance syndrome and sleep apnea range from
       conservative life style changes to moderately invasive oropharyngeal procedures.
       Continuous positive airway pressure (CPAP) is a very effective treatment in most
       situations, but requires good education and support to maintain proper
       compliance. Surgical procedures have not been tested by appropriate RCT
       methods.
   •   Some patients initially seek surgical care for snoring and have sleep apnea
       diagnosed to obtain insurance coverage for their surgery. Thorough sleep
       specialist evaluation of these patients is important.
   •   Treatment of snoring alone, without significant OSA, is not considered medically
       necessary and is not covered.

Lifestyle

   •   Avoid sleep deprivation
   •   Avoid the use of alcohol, sedatives, and hypnotic agents
   •   Lose weight
   •   Sleep apnea may be position-dependent. Most commonly, flat on the back is
       worse. Sleeping in lateral recumbent position may be helpful.
   •   Quit smoking




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Medical Treatment

         1. Oral Appliances

      Bluegrass Family Health covers custom-fitted and prefabricated oral appliances as
      durable medical equipment (DME) for OSA patients who have mild sleep apnea
      and meet the criteria for coverage of CPAP (see below), but who are intolerant to
      CPAP.

      Some oral appliances are custom-fitted by a dental laboratory, whereas others are
      prefabricated units that are adapted in a clinician’s office. Oral appliances for
      OSA that are available over-the-counter without a prescription are not covered.

      Dental rehabilitation (dentures, bridgework, etc.) as treatment for OSA is not
      covered.

         2. C-PAP

         Definition- A continuous flow of air is delivered at low pressure from a
         blower to a nasal mask held in place by head straps. This prevents collapse of
         oropharyngeal passage with resultant obstruction of airflow during sleep.
         Continuous positive airway pressure (CPAP) uses a constant air pressure.
         BiPAP uses two pressures, higher during inhalation and lower during
         exhalation.

             C-PAP is covered as DME for the treatment of OSA when ALL of the
             following criteria are met:

                 a. Sleep Study Results:

                         •   Patient's Apnea-Hypopnea Index (AHI) (also called the
                             Respiratory Disturbance Index or RDI) is greater than 15
                             regardless of symptoms; OR
                         •   AHI > 5 and < 15 if two or more of the following are met
                             (No coverage provided for RDI < 5):




                        i.   >20 episodes of oxygen desaturation < 85% or any one
                             episode of oxygen desaturation < 70%;
                       ii.   Type II second degree heart block or pause > 3 seconds or
                             ventricular tachycardia at a rate > 140/minute lasting > 15
                             complexes;
                      iii.   Excessive daytime sleepiness documented by Epworth >10
                             (see appendix).


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                iv.    Documented symptoms of impaired cognition, mood
                       disorders, or insomnia
                 v. Documented Hypertension (systolic blood pressure > 160
                       mmHg and/or diastolic blood pressure > 90 mmHg).
                vi. Documented ischemic heart disease.
           b. There is documentation that the member has been counseled
              regarding the importance of weight loss and/or smoking cessation
              (if applicapable) and the impact on OSA.

           * If the patient has marked snoring even though the apnea is mild, the
           last hour of the study should be used for a CPAP trial to evaluate the
           effect on both the degree of apnea and the intensity of snoring.

CPAP will not be authorized if the patient is not compliant (minimum of 4 hours
per 24 hour period) with its use.


BiPAP, and AutoPAP are covered as DME for patients who have documented
intolerance to CPAP. These alternatives to CPAP may also be covered for OSA
patients with concomitant breathing disorders which include restrictive thoracic
disorders, COPD, and nocturnal hypoventilation.

Bluegrass Family Health will cover humidifiers for CPAP devices if medically
indicated and documented need from prescribing physician is provided. For
coverage of heated humidifier, documentation should include failure of plain
and/or cool mist devices (documentation should include symptoms, i.e. nose and
throat dryness, irritation, burning sensation or secondary sinus discomfort or
headache, and failure of conservative treatment such as flushing each nostril with
salt solution and/or the use of a room vaporizer). The device should either be
attached to the CPAP device (K0268) or be internal to the device (K0193).

Consistent with Medicare Part B guidelines, supplies (e.g., mask, hose, rings, and
seals) are covered that are necessary for the effective use of a covered positive
airway pressure device.

Bluegrass Family Health covers replacements, repairs and maintenance of durable
medical equipment that is not provided for under a manufacturer’s warranty or
purchase agreement when it is functionally necessary and appropriate.

Upon individual review, positive airway pressure devices may be covered as a
form of noninvasive ventilation for patients with lung disease without OSA.
Requests for these devices for noninvasive ventilation of patients with lung
disease should be forwarded to the medical director for review.




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Clinical Indications for Surgery or Invasive Treatment

•   Success for most surgical procedures is defined as a greater than 50% drop in RDI
    (Respiratory Disturbance Index) or AI (Apnea Index) and an RDI less than 20 or
    AI less than 10

    Bluegrass Family Health does not require precertification for UPPP, however
    members may be eligible for coverage when the patient criteria below are met:

       1. Uvulopalatopharyngoplasty (UPPP)

    Uvulopalatopharyngoplasty is used to treat OSA by enlarging the oropharynx; it
    is covered for OSA patients who meet the criteria for CPAP (see above), but who
    are intolerant to CPAP. Patients should have documented attempt to use CPAP
    and weight loss (if BMI > 30) before considering surgery. (Please see BMI Table
    in the Appendix below.)

       o   One small RCT comparing CPAP with UPPP demonstrated a positive
           outcome with surgery in only one third of patients.
       o   Oral appliances were better than UPPP in one RCT.
       o   Indications for UPPP:
               § Patient should have tried CPAP with well-supported follow-up and
                   clear documentation of intolerance with a minimum one month
                   trial, and
               § Sleep apnea is mild to moderate as demonstrated by sleep study,
                   and
               § EDS is well-documented and interferes significantly with daily
                   activity, and
               § Retro-palatal narrowing demonstrated as the primary source of
                   airway obstruction, and
               § Review and verification of all the above by a sleep disorders
                   specialist independent of the surgeon.
               § In mild OSA if BMI is <35 and LSAT >85%
       o   UPPP not indicated if:
               § Early frustration, with CPAP called a “failure” (UPPP has been
                   found to be most reliably effective in OSA patients who have
                   adequately responded to a trial of CPAP. If CPAP is unsuccessful
                   in relieving a patient’s symptoms, this procedure will not be
                   covered because the appropriateness of a surgical approach has not
                   been supported.
               § Snoring is major complaint and EDS or OSA are not well
                   documented or described.
               § UARS
                        § Generally not indicated
       o   Presence of co-existing hypertension, CAD, or CVD is not an indication
           for skipping medical management of OSA and performing a UPPP sooner.



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        o Relapse of sleep apnea is common after UPPP. Relapse often requires
          renewed CPAP therapy.
              § Weight gain is major factor in relapse.
        o Follow-up sleep study or a careful symptoms survey should be done 12
          months after surgery to document continued effectiveness of surgery.




        1. Laser assisted uvuloplasty (LAUP)

     Laser assisted uvuloplasty has not been shown to be as effective as UPPP in the
     treatment of OSA. However, Bluegrass Family Health may extend coverage for
     this procedure in patients with severe OSA who have other medical conditions
     that make them unable to undergo UPPP and have failed a trial of CPAP or the
     use of an oral appliance or device. Such approval requires a case-by-case review
     by a medical director.

        2.   Somnoplasty

     Bluegrass Family Health does not cover radiofrequency ablation of the soft palate
     (Somnoplasty) because there is inadequate scientific evidence to validate its
     effectiveness in treating OSA.

        4. The Repose system

     Bluegrass Family Health does not cover the Repose system, a new minimally
     invasive technique involving tongue base suspension, because it still is considered
     investigational in nature. This procedure has been used for treating sleep
     disordered breathing (SDB) caused by tongue base collapse. No specific criteria
     exist regarding the diagnosis of tongue base collapse in SDB. Preliminary short-
     term studies of surgery targeted to alleviate tongue base collapse in SDB have
     shown subjective improvements in snoring and statistically significant decreases
     in mean RDI. However, the reported rates of success have been inconsistent
     among studies, and larger controlled studies with long-term follow-up are
     necessary to determine whether the Repose system is safe and effective.
     The history and physical examination has been shown to be sensitive but not
     specific for diagnosing OSAS in children. Treatment depends on the severity of
     symptoms and the underlying anatomic and physiologic abnormalities. Since
     childhood OSAS is usually associated with adenotonsillar hypertrophy, and the
     available medical literature suggests that the majority of cases are amenable to
     and will benefit from tonsillectomy and adenoidectomy.

5.    Jaw realignment surgery (i.e., hyoid myotomy and suspension, mandibular
     osteotomy, genioglossal advancement)




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     According to the medical literature, jaw realignment surgery is generally reserved
     for those patients who fail other treatment approaches for OSA.
     Although jaw realignment surgery may be covered, because of the extent of
     surgery, these cases must be reviewed by medical director for determination of
     medical necessity.

     According to the medical literature, patients undergoing jaw realignment surgery
     must usually also undergo orthodontic therapy to correct changes in occlusion
     associated with the surgery. Orthodontic therapy (i.e., the placement of
     orthodontic brackets and wires) is excluded from coverage under our medical
     plans regardless of medical necessity. Benefits for orthodontic therapy may be
     available under the member's dental plan. Requests for orthodontic therapy should
     be directed to the dental plan for review.

6.   Tracheostomy

     Requests for tracheostomy for OSA are reviewed on a case-by-case basis by a
     medical director. Its use is reserved for those patients with the most severe sleep
     apnea not manageable by other interventions.


     Clinical Indications for Hospitalization

           §   Not indicated


     Background
     Airway obstruction during sleep is a commonly recognized problem which may
     be associated with significant morbidity. Various diagnostic studies and treatment
     approaches are employed in managing this condition.
     Data from the history and physical examination have been shown to be sensitive
     but not specific for diagnosing OSA. Overnight polysomnography has become the
     definitive diagnostic tool of choice to confirm the presence and severity of upper
     airway obstruction in adults and children.

     According to the available literature, a minimum 6-hour NPSG is preferred,
     which allows for the assessment of variability related to sleep stage and position
     with respect to the frequency of obstructive respiratory events and the occurrence
     of other types of nocturnal events such as periodic limb movements. According to
     the available literature, standard NPSG should include electroencephalogram
     (EEG), electrooculogram (EOG), electromyogram (EMG), oronasal airflow, chest
     wall effort, body position, snore microphone, electrocardiogram (ECG), and
     oxyhemoglobin saturation. Standard diagnostic NPSG may be performed in a
     healthcare facility, or for appropriate cases, in the patient's home with a trained
     technologist in attendance. The use of unattended, standard diagnostic NPSG in
     the patient's home is not a validated clinical technique.



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According to the AASM, split-night study NPSG is indicated for patients with an
AHI > 40 events per hour during the first 2 hours of a diagnostic NPSG. Split-
night studies may also be considered for patients with an AHI of 20 to 40 events
per hour, based on clinical observations, such as the occurrence of obstructive
respiratory events with a prolonged duration or in association with severe oxygen
desaturation. Split-night studies require the recording and analysis of the same
parameters as a standard diagnostic NPSG. Accepted guidelines provide that the
diagnostic portion of a split-night study should be at least 2 hours duration. A
minimum of 3 hours sleep is preferred to adequately titrate CPAP after this
treatment is initiated.

On a subsequent night following a standard diagnostic NPSG, the available
literature indicates that OSA patients should receive CPAP titration to specify the
lowest CPAP level, which abolishes obstructive apneas, hypopneas, respiratory-
effort related arousals, and snoring in all sleep positions and sleep stages. On
occasion, an additional full-night CPAP titration NPSG may also be required
following split-night study if the split-night NPSG did not allow for the
abolishment of the vast majority of obstructive respiratory events or prescribed
CPAP treatment does not control clinical symptoms.

Because limited channel NPSG has been shown to be less accurate than a
standard NPSG in determining the number of obstructive respiratory events and
does not detect non-OSA sleep disorders that may coexist with OSA, its use is
recommended only in patients with a high pretest probability of OSA based on
validated screening algorithms. Limited channel NPSG should include the
following minimum parameters: oronasal airflow, chest wall effort, ECG, and
oxyhemoglobin saturation.
Accepted guidelines indicate that nocturnal pulse oximetry alone is not
appropriately used as a case finding or screening method to rule out OSA. Pulse
oximetry, when used alone, has not been show to have an adequate negative
predictive value to rule out OSA (i.e., all patients with symptoms suggestive of
OSA would require polysomnography regardless of whether the pulse oximetry
was positive or negative).

The MESAM and the static charge sensitive bed have not been proven to be valid
devices for screening or diagnosing OSA. Actigraphy has not been validated as a
method of screening or diagnosing OSA although it may be a useful adjunct to
other procedures in the evaluation of sleep disorders.

Uvulopalatopharyngoplasty, jaw realignment surgery, positive airway pressure
devices (e.g., CPAP, BiPAP, etc.), tracheostomy, tonsillectomy and
adenoidectomy, and orthodontic devices such as the tongue retaining device, may
be effective treatments for properly selected patients with obstructive sleep apnea.




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A variety of oral appliances and prostheses, including tongue retainers and
mandibular advancing devices, have been used to treat patients with OSA. These
devices modify the airway by changing the posture of the mandible and tongue. A
task force of the Standards of Practice Committee of the ASDA concluded that,
despite the considerable variation in the design of these devices, their clinical
effects in improving OSA have been consistent.

These devices have been shown to be effective in alleviating OSA, and present a
useful alternative to CPAP or surgery. Oral appliances, however, have been
shown to be less reliable and effective than CPAP, and therefore the literature
suggests that their use should be reserved for patients who are intolerant of CPAP.
Patients with OSA suffer from numerous apneic events while sleeping, due to
collapse of the upper airway during inspiration. Continuous positive airway
pressure, and more recently, BiPAP, DPAP, VPAP, and AutoPAP, have been
used in the treatment of OSA as a means of serving as a "pneumatic splint" in
order to prop open the airways during inspiration.
Bilevel positive airway pressure, DPAP, VPAP, and AutoPAP have been shown
to be effective alternatives to CPAP, but are indicated only as second line
measures for patients who are intolerant to CPAP. These alternatives to CPAP
may also be indicated for OSA patients with concomitant breathing disorders to
include restrictive thoracic disorders, COPD, and nocturnal hypoventilation.

Jaw realignment is an aggressive, multistep procedure requiring a three to six
month interval between each step. The ASDA concluded that inferior sagittal
mandibular osteotomy and genioglossal advancement with or without hyoid
myotomy and suspension appears to be the most promising of procedures directed
at enlarging the retrolingual region. Jaw fixation is necessary for two to three
weeks following surgery, and a soft diet is necessary for a total of six weeks.
Patients undergoing jaw realignment surgery must usually also undergo
orthodontic therapy to correct changes in occlusion associated with the surgery.
Jaw realignment surgery is generally reserved for those patients who fail other
treatment approaches for OSA.

Tracheostomy, which simply bypasses the obstructing lesion of the upper airways,
has been shown to be the most effective and predictable surgical approach to
OSA. However, the social and medical morbidities of a permanent tracheostomy
and the advent of surgical alternatives have made tracheostomy an unpopular
solution to OSA, reserved for those patients with the most severe sleep apnea not
manageable by other interventions.

Appendix:

Epworth Sleepiness Scale
Indicate the likelihood of falling asleep in the following commonly encountered
situations. Assign the following scores to the patient's responses:
Likelihood of dozing      Score



                                                                                  12
None                      0
Low chance                1
Moderate chance           2
High chance               3

     a.   Sitting and reading
     b.   Watching TV
     c.   Sitting, inactive, in a public place, i.e., theater
     d.   As a passenger in a car for an hour without a break
     e.   Lying down to rest in the afternoon when circumstances permit
     f.   Sitting and talking to someone
     g.   In a car, while stopped for a few minutes in traffic

Sum the scores. A total greater than 10 is considered abnormal.

Body Mass Index
Body Mass Index (BMI) equals weight in kilograms divided by height in meters
squared:

          BMI = weight (kg) [height (m)] ²

Alternatively, BMI may be calculated as weight in pounds divided by height in
inches squared, multiplied by 703:

          BMI = (weight (lbs) [height (inches)] ²) 703

A BMI calculator can be found at the following
website: http://www.nhlbisupport.com/bmi/
Heights and Weights Corresponding to BMI of 30:
Height                  Weight in pounds (without clothes)
                        corresponding to a BMI of 30 kg/m2
(inches)

58                      143

59                      148

60                      153

61                      158

62                      164

63                      169


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   64                     174

   65                     180

   66                     186

   67                     191

   68                     197

   69                     203

   70                     209

   71                     215

   72                     221

   73                     227

   74                     233

   75                     240

   76                     246




   Application to products:
   Unless indicated otherwise above, this policy applies to all fully insured Bluegrass
   Family Health HMO, POS and PPO plans, unless a specific limitation or
   exception exists. With respect to fully insured plans and self - funded non -
   ERISA (e.g., government, school boards, church) plans, applicable state mandates
   will take precedence over either. Unless otherwise specifically excluded, Federal
   mandates will apply to all plans.

   Place of Service:
   Inpatient (overnight) or outpatient (home)


   The above policy is based on the following references:

1. Medicare Coverage Issues Manual §60-17, Continuous Positive Airway Pressure.
2. Hayes, Inc. Medical Technology Assessment: Sleep Apnea Treatment, Devices,
   Aug. 1999; Sleep Apnea Treatment, Medical, Nov. 1997; Sleep Apnea
   Treatment, Surgical, Feb. 1999; Sleep Apnea, Diagnosis, Adult, July, 1999.


                                                                                     14
3. McKesson, Interqual Products Group; Polysomnogram, Home/Overnight, ISP
    Review, 2001; Uvulopalatopharyngoplasty (UPPP), ISP Review, 2001.
4. Milliman, Inc., M&R Care Guidelines, 2001 Obstructive Sleep Apnea.
5. Apollo Managed Care Consultants; Medical Review Criteria Guidelines for
    Managed Care: CPAP for Obstructive Sleep Apnea Syndrome (OSAS), Aug.
    2000; Sleep Apnea Studies, Noninvasive, Positive Pressure Ventilation, Feb.
    2001.
6. Practice parameters for the indications for polysomnography and related
    procedures. Polysomnography Task Force, American Sleep Disorders Association
    Standards of Practice Committee. Sleep. 1997; 20(6):406-422.
7. American Sleep Disorders Association, Standards of Practice Committee. Practice
    Parameter for the Use of Portable Recording of the Assessment of Obstructive
    Sleep Apnea. Sleep. 1994;17(4):372-377.
8. American Sleep Disorders Association, Standards of Practice Committee. Practice
    Parameters for the use of Laser-Assisted Uvulopalatoplasty: An American Sleep
    Disorders Association Report. Sleep. 1994;17(8):744-748.
9. American Sleep Disorders Association, Standards of Practice Committee. The
    Clinical Use of the Multiple Sleep Latency Test: An American Sleep Disorders
    Association Report. Sleep 1992;15(3):268-276.
10. American Sleep Disorders Association, Standards of Practice Committee. Practice
    Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral
    Appliances. Sleep. 1995;18(6):511-513.
11. Hillberg RE, and Johnson DC. Current Concepts: Noninvasive Ventilation. N
    Engl J Med. 1997; 337(24):1746-1752.
12. Schmidt-Nowara W, Lowe A, Wiegand L, et al. Oral Appliances for the
    Treatment of Snoring and Obstructive Sleep Apnea: An American Sleep
    Disorders Association Review. Sleep. 1995;18(6):501-510.
13. Wright J, Johns R, Watt I, et al. Health Effects of Obstructive Sleep Apnea and
    the Effectiveness of Continuous Positive Airways Pressure: A Systematic Review
    of the Research Evidence. BMJ. 1997;314 (7084):860.
14. Loube DI, et al. Indications for positive airway pressure treatment of adult
    obstructive sleep apnea patients: a consensus statement. Chest. 1999 Mar; 115(3):
    863-866.
15. Agency for Healthcare Policy and Research. Systematic Review of the Literature
    Regarding the Diagnosis of Sleep Apnea. Evidence Report/Technology
    Assessment No. 1. AHCPR Publication No. 99-E002. Bethesda, MD: AHCPR,
    December 1998.
16. Coleman J. Sleep studies. Current techniques and future trends. Otolaryngol Clin
    North Am. 1999;32(2):195-210.
17. Olson LG, Ambrogetti A, Gyulay SG. Prediction of sleep-disordered breathing by
    unattended overnight oximetry. J Sleep Res. 1999;8(1):51-55.
18. Epstein LJ, Dorlac GR. Cost-effectiveness analysis of nocturnal oximetry as a
    method of screening for sleep apnea-hypopnea syndrome. Chest. 1998;113(1):97-
    103.




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19. Lacassagne L, Didier A, Murris-Espin M, et al. Role of nocturnal oximetry in
    screening for sleep apnea syndrome in pulmonary medicine. Study of 329
    patients. Rev Mal Respi.r 1997;14(3):201-207.
20. Chesson AL Jr, Ferber RA, Fry JM, et al. The indications for polysomnography
    and related procedures. Sleep .1997;20(6):423-487.
21. McNicholas WT. Clinical diagnosis and assessment of obstructive sleep apnoea
    syndrome. Monaldi Arch Chest Dis. 1997;52(1):37-42.
22. Levy P. Pepin JL. Deschaux-Blanc C Paramelle B. et al. Accuracy of oximetry for
    detection of respiratory disturbances in sleep apnea syndrome. Chest. 1996;
    109(2):395-399.
23. Ryan PJ, Hilton MF, Boldy DA, et al. Validation of British Thoracic Society
    guidelines for the diagnosis of the sleep apnoea/hypopnoea syndrome: can
    polysomnography be avoided? Thorax. 1995;50(9):972-975.
24. Series F, Marc I, Cormier Y, LaForge J. Utility of nocturnal home oximetry for
    case finding in patients with suspected sleep apnea hypopnea syndrome. Ann Int
    Med. 1993;119:449-453.
25. Stoohs R, Guilleminault C. MESAM 4: An ambulatory device for the detection of
    patients at risk for obstructive sleep apnea. Chest. 1992 101(5)1221-1227.
26. Fibbi A, Presta A, Fasciolo G. The REPOSE system. Acta Otorhinolaryngol Ital.
    1999;19(1):21-25. 23.Coleman J, Bick PA. Suspension sutures for the treatment
    of obstructive sleep apnea and snoring. Otolaryngol Clin North Am.
    1999;32(2):277-285. 24. Troell RJ, Riley RW, Powell NB, Li K. Surgical
    management of the hypopharyngeal airway in sleep disordered breathing.
    Otolaryngol. Clin North Am. 1998;31(6):979-1012.
27. Teschler H, Stampa JW, Farhat AA, et al. Comparison of the efficacy of BiPAP-
    S/T and the VPAP-S/T ventilators in patients with stable chronic respiratory
    insufficiency. Pneumologie. 1998; 52(6):305-310.
28. Schulz R, Mahmoudi S, Hattar K, et al. Enhanced release of superoxide from
    polymorphonuclear neutrophils in obstructive sleep apnea. Impact of continuous
    positive airway pressure therapy. Am J Respir Crit Care Med. 2000;162(2 Pt
    1):566-570.
29. Bloch KE, Iseli A, Zhang JN, et al. A randomized, controlled crossover trial of
    two oral appliances for sleep apnea treatment. Am J Respir Crit Care Med.
    2000;162(1):246-251.
30. Series F. Accuracy of an unattended home CPAP titration in the treatment of
    obstructive sleep apnea. Am J Respir Crit Care Med. 2000;162(1):94-97.
31. Wright J, White J. Continuous positive airways pressure for obstructive sleep
    apnoea. Cochrane Database Syst Rev. 2000;(2):CD001106.
32. Tun Y, Hida W, Okabe S, et al. Effects of nasal continuous positive airway
    pressure on awake ventilatory responses to hypoxia and hypercapnia in patients
    with obstructive sleep apnea. Tohoku J Exp Med. 2000;190(2):157-168.
33. Kingshott RN, Vennelle M, Hoy CJ, et al. Predictors of improvements in daytime
    function outcomes with CPAP therapy. Am J Respir Crit Care Med. 2000;161(3
    Pt 1):866-871.




                                                                                 16
34. Findley L, Smith C, Hooper J, et al. Treatment with nasal CPAP decreases
    automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med.
    2000;161(3 Pt 1):857-859.
35. Fletcher EC, Stich J, Yang KL. Unattended home diagnosis and treatment of
    obstructive sleep apnea without polysomnography. Arch Fam Med.
    2000;9(2):168-174.
36. Javaheri S. Effects of continuous positive airway pressure on sleep apnea and
    ventricular irritability in patients with heart failure. Circulation. 2000;101(4):392-
    397.
37. Woodson BT, Derowe A, Hawke M, et al. Pharyngeal suspension suture with
    repose bone screw for obstructive sleep apnea. Otolaryngol Head Neck Surg.
    2000;122(3):395-401.
38. DeRowe A, Gunther E, Fibbi A, et al. Tongue-base suspension with a soft tissue-
    to-bone anchor for obstructive sleep apnea: preliminary clinical results of a new
    minimally invasive technique. Otolaryngol Head Neck Surg. 2000;122(1):100-
    103.
39. . Kump K, et al. Assessment of the validity and utility of a sleep-symptom
    questionnaire. American Journal of Respiratory and Critical Care Medicine
    1994;150(3):735-41. [ Context Link 1, 2 ]
40. Deegan PC, McNicholas WT. Predictive value of clinical features for the
    obstructive sleep apnoea syndrome. European Respiratory Journal 1996;9(1):117-
    24. [ Context Link 1, 2, 3 ]
41. Netzer NC, et al. Using the Berlin Questionnaire to identify patients at risk for the
    sleep apnea syndrome. Annals of Internal Medicine 1999;131(7):485-91. [
    Context Link 1 ]
42. Chervin RD, Aldrich MS. The Epworth Sleepiness Scale may not reflect objective
    measures of sleepiness or sleep apnea. Neurology 1999;52(1):125-31. [ Context
    Link 1 ]
43. Osman EZ, et al. The Epworth Sleepiness Scale: can it be used for sleep apnoea
    screening among snorers? Clinical Otolaryngology 1999;24(3):239-41. [ Context
    Link 1 ]
44. Kramer NR, Bonitati AE, Millman RP. Enuresis and obstructive sleep apnea in
    adults. Chest 1998;114(2):634-7. [ Context Link 1 ]
45. Fry JM, et al. Full polysomnography in the home. Sleep 1998;21(6):635-42. [
    Context Link 1 ]
46. Exar EN, Collop NA. The upper airway resistance syndrome. Chest
    1999;115(4):1127-39. [ Context Link 1, 2, 3 ]
47. Barthel SW, Strome M. Snoring, obstructive sleep apnea, and surgery. Medical
    Clinics of North America 1999;83(1):85-96. [ Context Link 1 ]
48. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of
    the upper airway in adults with obstructive sleep apnea syndrome. Sleep
    1996;19(2):156-77. [ Context Link 1, 2, 3, 4, 5, 6, 7 ]
49. White DP, Gibb TJ. Evaluation of the Healthdyne NightWatch system to titrate
    CPAP in the home. Sleep 1998;21(2):198-204. [ Context Link 1 ]
50. Series F, Marc I. Efficacy of automatic continuous positive airway pressure
    therapy that uses an estimated required pressure in the treatment of the obstructive



                                                                                       17
    sleep apnea syndrome. Annals of Internal Medicine 1997;127(8 Pt 1):588-95. [
    Context Link 1 ]
51. Lloberes P, et al. Comparison of manual and automatic CPAP titration in patients
    with sleep apnea/hypopnea syndrome. American Journal of Respiratory and
    Critical Care Medicine 1996;154(6 Pt 1):1755-8. [ Context Link 1 ]
52. McArdle N, et al. Long-term use of CPAP therapy for sleep apnea/hypopnea
    syndrome. American Journal of Respiratory and Critical Care Medicine
    1999;159(4 Pt 1):1108-14. [ Context Link 1 ]
53. Loube DI, et al. Indications for positive airway pressure treatment of adult
    obstructive sleep apnea patients: a consensus statement. Chest 1999;115(3):863-6.
    [ Context Link 1 ]
54. Marklund M, et al. The effect of a mandibular advancement device on apneas and
    sleep in patients with obstructive sleep apnea. Chest 1998;113(3):707-13. [
    Context Link 1 ]
55. Millman RP, et al. The efficacy of oral appliances in the treatment of persistent
    sleep apnea after uvulopalatopharyngoplasty. Chest 1998;113(4):992-6. [ Context
    Link 1, 2 ]
56. Wilhelmsson B, et al. A prospective randomized study of a dental appliance
    compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep
    apnoea. Acta Oto-Laryngologica 1999;119(4):503-9. [ Context Link 1, 2, 3 ]
57. Utley DS, et al. A cost-effective and rational surgical approach to patients with
    snoring, upper airway resistance syndrome, or obstructive sleep apnea syndrome.
    Laryngoscope 1997;107(6):726-34. [ Context Link 1, 2 ]
58. Lojander J, et al. Nasal-CPAP, surgery, and conservative management for
    treatment of obstructive sleep apnea syndrome. A randomized study. Chest
    1996;110(1):114-9. [ Context Link 1, 2 ]
59. Aetna USHC Medical Policy Bulletin # 0004 at
    http://www.aetna.com/cpb/data/CPBA0004.html
60. Janson C, et al. Long-term follow-up of patients with obstructive sleep apnea
    treated with uvulopalatopharyngoplasty. Archives of Otolaryngology. Head and
    Neck Surgery 1997;123(3):257-62. [ Context Link 1 ]
61. Lojander J, et al. Cognitive function and treatment of obstructive sleep apnea
    syndrome. Journal of Sleep Research 1999;8(1):71-6. [ Context Link 1 ]




   Bluegrass Family Health Policies are developed to assist in administering plan
   benefits and constitute neither offers of coverage nor medical advice. This Policy
   contains only a partial, general description of plan or program benefits and does
   not constitute a contract. Bluegrass Family Health does not provide health care
   services and, therefore, cannot guarantee any results or outcomes. Participating
   providers are independent contractors in private practice and are neither
   employees nor agents of Bluegrass Family Healthor its affiliates. Treating
   providers are solely responsible for medical advice and treatment of members.
   This Policy may be updated and therefore is subject to change.


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November 25, 2001




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