Polysomnography is indicated for the diagnosis of certain sleep related disorders. Standard polysomnography (also known as Type I monitor) is performed in a sleep lab, hospital, or other dedicated unit and is attended by a sleep technologist. It includes measurements of O₂ saturation, electrocardiography (EKG, ECG), electroencephalography (EEG), electromyography (EMG), electrooculography (EOG), airflow, and respiratory effort measurements. The study identifies sleep architecture, number and degree of arousals, number and type of apneic episodes, episodes of oxygen desaturation and severity, cardiac arrhythmias, limb movements, disorders associated with REM sleep, and seizure activity.

Note: This guideline addresses the indications for polysomnography studies for adults and children.  For information related to other technologies utilized in the diagnosis and management of sleep-related disorders, please see:

• MED.00002 Diagnosis of Sleep Disorders;
• MED.00054 Treatment for Obstructive Sleep Apnea in Adults;
• SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA);
• Clinical UM Guideline CG-DME-27 Non-invasive Positive Pressure Respiratory Assist Devices (BiPAP®).

Medically Necessary:

1. Polysomnography in Adults

Polysomnography for adults is considered medically necessary in the diagnosis of the following conditions:

• Sleep-related breathing disorders such as obstructive sleep apnea, upper airway resistance syndrome;
• Narcolepsy or idiopathic hypersomnia (performed in conjunction with a multiple sleep latency test);
• Sleep-related violent or injurious behavior, e.g., REM behavior disorder or suspected nocturnal seizures;
• Periodic limb movements of sleep.

Indications for polysomnography for adults include one or more of the following {(1) through (8)}:


1. Witnessed apnea during sleep greater than 10 seconds in duration;OR
2. Any combination of two or more of the following {(a) through (d)}:
1. Excessive daytime sleepiness as evidenced by one or more of the following:
• Inappropriate daytime napping (e.g., during driving, conversation, or eating);
• Sleepiness that interferes with daily activities; (The following should be ruled out as a cause for these symptoms: poor sleep hygiene, medication, drugs, alcohol, hypothyroidism, other medical diagnoses, psychiatric, or psychological disorders, social or work schedule changes.)
• An Epworth Sleepiness Scale score greater than 10; or
2. Persistent or frequent socially disruptive snoring; or
3. Obesity (BMI greater than 30 kg/m²) or hypertension; or
4. Choking or gasping episodes associated with awakenings. OR
3. Symptoms suggesting narcolepsy, e.g., sleep paralysis, hypnagogic hallucinations, cataplexy. (Multiple sleep latency test would be required also here – see MED.00002 Diagnosis of Sleep Disorders for criteria.); OR
4. Violent or injurious behavior during sleep; OR
5. Other situations (if nocturnal pulse oximetry suggests nocturnal oxygen desaturation) such as:
• Unexplained right heart failure;
• Unexplained polycythemia;
• Presence of or increase in cardiac arrhythmias during sleep;
• Unexplained pulmonary hypertension. OR
6. Excessive daytime sleepiness together with witnessed periodic limb movements of sleep; OR
7. Unusual or atypical parasomnias based on patient's age, frequency, or duration of behavior; OR
8. Patient's with moderate or severe congestive heart failure, stroke/TIA, coronary artery disease, or significant tachycardic or bradycardic arrythymias who have nocturnal symptoms suggestive of a sleep related breathing disorder or otherwise suspected of having sleep apnea.
   
   

Repeat polysomnography for adults is considered medically necessary under the following circumstances:

• Failure of resolution of symptoms or recurrence of symptoms during treatment; OR
• Post-operatively following uvulopalatopharyngoplasty (UPPP) or other corrective surgeries for obstructive sleep apnea (due to the variable outcome of these surgical procedures); OR
• Following treatment with an oral appliance for obstructive sleep apnea with an apnea hypopnea index (an AHI) or respiratory disturbance index (RDI) of  >15 pre-treatment to ensure effective treatment; OR
• To titrate CPAP following an initial polysomnography where obstructive sleep apnea was demonstrated and a split night study was not feasible (see "split night studies" below); OR
• To reevaluate the diagnosis of obstructive sleep apnea and need for continued CPAP in a patient previously diagnosed by polysomnography and currently using CPAP, if a significant weight loss has occurred since the initial study.
  
  
Not Medically Necessary:

Two Separate Night Studies
Two separate nights’ polysomnography studies, one for the diagnosis of sleep disorders and the second to titrate CPAP, are generally considered not medically necessary unless circumstances do not allow for half night or “split night” polysomnography with titration of CPAP performed in the second part of the study, (e.g., significant obstructive sleep apnea, [that is with an AHI or RDI of 20 or more with oxygen desaturations], not identified in time to allow for at least 3 hours of CPAP titration including both REM and non-REM sleep).  In these cases, a second full night’s study may then be medically necessary for CPAP titration.

Repeat Polysomnography
Repeat polysomnography is considered not medically necessary in the follow-up of patients with obstructive sleep apnea treated with CPAP when symptoms attributable to sleep apnea have resolved.

Polysomnography for adults is considered not medically necessary for the following symptoms or conditions existing alone in the absence of other features suggestive of obstructive sleep apnea:


• Snoring;
• Obesity;
• Hypertension;
• Morning headaches;
• Decrease in intellectual functions;
• Memory loss;
• Frequent nighttime awakening;
• Other sleep disturbances such as insomnia (acute or chronic), night terrors, sleep walking, epilepsy where nocturnal seizures are not suspected;
• Common uncomplicated non-injurious parasomnias.
  
  
2. Polysomnography in Children

   Medically Necessary:
   
   Polysomnography for children is considered medically necessary for the diagnosis of the following conditions:
   

   • Sleep related breathing disorders, such as obstructive sleep apnea, upper airway resistance syndrome;
   • Narcolepsy or idiopathic hypersomnia (generally would be performed in conjunction with a multiple sleep latency test);
   • Central apnea or congenital central alveolar hypoventilation syndrome;
   • Periodic limb movements of sleep;
   • Nocturnal seizure activity;
   • REM behavior disorder (rare in childhood).
     
     

   Indications for polysomnography for childrenwhere obstructive sleep-disordered breathing is suspected, include one or more of the following {(a) through (g)}:
   

   1. Habitual snoring associated with one or more of the following:
   • Restless or disturbed sleep; or
   • Behavioral disturbance, or learning disorders including deterioration in academic performance, hyperactivity, or attention deficit disorder; or
   • Enuresis; or
   • Frequent awakenings; or
   • Failure to thrive or growth impairment. OR
   2. Witnessed apnea greater than 2 respiratory cycle times (inspiration and expiration); OR
   3. Excessive daytime somnolence, or altered mental status unexplained by other conditions or etiologies; OR
   4. Polycythemia unexplained by other conditions or etiologies; OR
   5. Cor pulmonale unexplained by other conditions or etiologies; OR
   6. Increased respiratory efforts, labored breathing, or sternal or intercostal retractions during sleep; OR
   7. 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.
      
      

   Repeat polysomnography for children is considered medically necessary in 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
   • A child with previously diagnosed and treated obstructive sleep apnea who continues to exhibit persistent snoring or other symptoms of sleep disordered breathing. In the case of adenotonsillectomy, repeat polysomnography should also be performed if the pre-operative obstructive sleep apnea was severe (RDI or AHI greater than 19). [If the treatment was surgical, testing should be deferred for 6 to 8 weeks post-operatively.]; OR
   • 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.
   
   

   Not Medically Necessary:

   Repeat Polysomnography
   Repeat polysomnography is considered not medically necessary in the follow-up of patients with obstructive sleep apnea treated with CPAP when symptoms attributable to sleep apnea have resolved.

   Polysomnography for children is considered not medically necessary for the following:
   

   • Sleep walking or night terrors;
   • Routine evaluation of adenotonsillar hypertrophy alone without other clinical signs or symptoms suggestive of obstructive sleep disordered breathing;
   • Routine follow-up for children whose symptoms have resolved post-adenotonsillectomy unless the pre-operative RDI or AHI was greater than 19 or the child continues to snore post-operatively or other symptoms related to pre-operative sleep disordered breathing persist or recur.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

95806	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist
95807	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
95808	Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist
95810	Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist
95811	Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist

ICD-9 Procedure

89.17

Polysomnogram

ICD-9 Diagnosis, including but not limited to, the following:

307.40-307.49	Specific disorders of sleep of non-organic origin
327.00-327.8	Organic sleep disorders
347.00-347.11	Cataplexy and narcolepsy
780.50-780.59	Sleep disturbances
786.09	Other dyspnea and respiratory abnormalities

A. Polysomnography in Adults
Based upon the available, peer-reviewed literature, in-laboratory attended polysomnography (PSG) is considered the gold standard for diagnosis of sleep-related disorders, including, but not limited to, obstructive sleep apnea, narcolepsy, nocturnal myoclonia and for titration of Continuous Positive Airway Pressure (CPAP). Multiple randomized clinical trials have established that a standard PSG should include the measurement of O₂ saturation, electrocardiography (EKG, ECG), electroencephalography (EEG), electromyography (EMG), electrooculography (EOG), airflow, and respiratory effort measurements. Exclusion of any of these measurements may lead to missing vital data needed to diagnose sleep disorders.

The medical literature contains numerous models that have been proposed in an attempt to identify the factors that could predict reliably the presence of obstructive sleep apnea (confirmed by polysomnography) in adults. These range from morphometric data, constellations of symptoms, and combinations of symptoms and physical findings, including such factors as obesity, neck circumference, snoring, hypertension, upper airway narrowing, etc. The American Academy of Sleep Disorders states that adult patients with habitual snoring, excessive daytime sleepiness, a BMI greater than 35 and observed apneas are at high risk for obstructive sleep apnea with at least a 75% likelihood of having an AHI (or RDI) equal to or greater than 10. Netzer, et al. in a 1999 article in the Annals of Internal Medicine used the "Berlin Questionnaire" with three groups of questions: one regarding snoring, the second regarding daytime sleepiness, and the third regarding the presence of hypertension or obesity. They found that positive responses in two out of the three categories had a sensitivity of 86%, a specificity of 77%, and a positive predictive value of 89%.

The prevalence of significant obstructive sleep apnea in adults as defined by an AHI (or RDI) of at least 5 associated with excessive daytime somnolence, has been demonstrated to be 4% in males and 2% in females in the 30 - 60 year old age group. However, the presence of snoring, hypertension or obesity in isolation, does not carry sufficient predictive value to warrant polysomnography in all individuals with these single complaints or conditions. (Snoring alone is said to occur in up to 40% of the population, and this increases over the age of 50 years.) The benefits of performing polysomnography in these large populations of individuals without other associated findings suggestive of sleep apnea are unproven.

The American Academy of Sleep Medicine has recently evaluated the evidence and determined that polysomnography is not indicated for the routine evaluation of transient insomnia, chronic insomnia, or insomnia associated with psychiatric disorders.

In a "split-night" study the patient begins a standard PSG. If after the first 2 or 3 hours enough data is gathered for a positive diagnosis of OSA, the patient is then asked to wear a CPAP nasal mask for the second part of the study to determine the most appropriate pressure setting (Peff) to relieve OSA symptoms.

B. Polysomnography in Children
Suspicion of the presence of obstructive sleep-disordered breathing or obstructive sleep apnea syndrome will be the case in the majority of children referred for polysomnography.  Obstructive sleep apnea syndrome in children is a disorder of breathing during sleep, characterized by prolonged partial upper airway obstruction and/or intermittent and complete obstruction, which may be accompanied by hypoxia, hypercapnia and disturbed sleep.  It occurs in approximately 2% of children at a peak of 2 to 6 years of age (habitual snoring occurs in 3% to 12% of preschool age children).  Most children with obstructive sleep apnea will have habitual snoring, and this may be accompanied by labored breathing or restlessness during sleep.  Daytime manifestations of sleep disordered breathing in children are more subtle, and may be more diverse than in adults.  Symptoms may include behavioral problems and neuro-cognitive dysfunction with a nearly three-fold increase in children with sleep-disordered breathing.  Although the precise relationship between sleep-disordered breathing and attention deficit hyperactivity disorder (ADHD) is unknown, it appears that sleep-disordered breathing may exacerbate ADHD, and that some children with hyperactivity caused by sleep-disordered breathing may be misdiagnosed as having ADHD.  The possible relationship is strengthened by the observation that children with ADHD have high rates of sleep complaints and disturbances.  It is recommended that children who snore and carry a diagnosis of ADHD should be evaluated for the possibility that sleep-disordered breathing is causing or exacerbating the behavioral symptoms.  While excessive daytime sleepiness may be present in approximately 20% of children with obstructive sleep apnea syndrome, this symptom occurs less frequently than in adults.

Although obstructive sleep apnea syndrome in children is commonly related to the presence of adenotonsillar hypertrophy, other factors related to dynamic airway collapse appear to be involved.  In otherwise normal children with obstructive sleep apnea syndrome, it is felt that adenotonsillar hypertrophy causes airway narrowing that, when superimposed on subtle abnormalities of upper airway motor control or tone, leads to clinically significant dynamic airway obstruction during sleep. However, the adenotonsillar size or volume, in and of itself, has not been shown to have a simple-relationship with the presence of obstructive sleep apnea in children.  Routine polysomnography in children with adenotonsillar hypertrophy, in the absence of other suggestive signs or symptoms of obstructive sleep-disordered breathing, is not recommended.  By the same token, routine polysomnography post-adenotonsillectomy, in a child with pre-existing mild to moderate obstructive sleep apnea whose symptoms have resolved post-operatively, is not recommended. However, follow-up polysomnography is recommended post-operatively in the case of a child with pre-existing severe obstructive sleep apnea (RDI or AHI greater than 19).

Other factors that may place the child at risk for obstructive sleep-disordered breathing include: neuromuscular disease associated with either hypotonia or hypertonia; genetic syndromes associated with craniofacial abnormalities, such as midface hypoplasia, micrognathia or small nasopharynx; narrow high arched hard palate, long soft palate, or shallow pharyngeal area; prematurity or African-American ethnicity (in certain age groups).

The diagnosis of sleep-disordered breathing in children is most definitively established by performing overnight polysomnography in a sleep lab setting.  However, what constitutes normal or abnormal respiratory events during sleep, and the clinical significance and/or implications of these are not as well established or defined as in the adult population.  The natural history of childhood obstructive sleep apnea is not well understood, and the mortality rate in childhood obstructive sleep apnea is unknown.  It should also be noted that normative polysomnography data in children differs from that in adults.  There are no widely accepted standardized guidelines or diagnostic criteria for classic obstructive sleep apnea in children.  The 2002 Clinical Practice Guidelines from the American Academy of Pediatrics state the following:  “Although we know which polysomnographic parameters are statistically abnormal, studies have not definitively evaluated which polysomnographic criteria predict morbidity.”  Nevertheless, most children in whom a diagnosis is made will undergo adenotonsillectomy which will be corrective in 75% - 100% of cases.

C. Description of Sleep Disorders
Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life, productivity, and health. There are many different types of sleep-related disorders including sleep apnea, upper airway resistance syndrome, insomnia, narcolepsy, nocturnal movement disorders such as Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD), unexplained excessive daytime sleepiness, and arousal disorders (parasomnias). Most, if not all, of these sleep-related disorders are treatable if diagnosed properly.

Sleep disorder studies, including polysomnography and multiple sleep latency testing, are used to determine or confirm a diagnosis related to sleep disturbances. These tests monitor various bodily functions, including heart and respiratory rate, body position and movement, to gain an understanding of the conditions under which sleep disturbances occur. Obstructive sleep apnea represents a very large portion and is the focus of this policy. Another type of sleep disturbance is simply known as "apnea" or "central apnea." This condition, caused by problems in the central nervous system, is unrelated to obstructive sleep apnea and is not addressed in this policy.

D. Description of Sleep Studies
Polysomnogram (PSG) sleep studies are routinely performed at sleep study centers, either at a hospital or at stand-alone facilities. During the test, a number of sensors are applied to the patient to monitor his or her breathing, heart rate, and other measurements. The patient is then allowed to sleep overnight. Throughout the test, technicians record and monitor the readings received from the sensors. Technicians may need to re-attach loosened sensors if any should need adjustment. One of the criteria for sleep studies is abnormal daytime sleepiness. This is usually measured using a widely used tool called the Epworth Sleepiness scale (see below). A score of greater than or equal to 21 is considered excessive daytime sleepiness, but in clinical practice a score of greater than 10 is considered abnormal and requiring medical attention.

E. The Epworth Sleepiness Scale
The following scale is used to rate answers to the questions below:
0 = No chance of dozing, 1 = Slight chance of dozing, 2 = Moderate chance of dozing, 3 = High chance of dozing

A. Polysomnography (Adults):

1. Chesson AL Jr, Ferber RA, Fry JM, et al. The indications for polysomnography and related procedures. Sleep. 1997; 20(6):423-87.
2. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999; 131(7):485-91.
3. Flemons WW. Obstructive sleep apnea, New England Journal of Medicine. 2002; 347(7):498-504.
4. Guilleminault C, Abad VC. Obstructive sleep apnea syndromes. Med Clin North Am. 2004; 88(3):611-30
5. Kushida CA. A predictive morphometric model for the obstructive sleep apnea syndrome. Ann Int Med. 1997; 127(8) Pt1:581-7.
6. Littner M, et al. Practice5 parameters for Using Polysomnography to Evaluate Insomnia: An Update. Sleep. 2003 26(6):754-60.
7. Chesson AL Jr, Berry RB, Pack A; American Academy of Sleep Medicine; American Thoracic Society; American College of Chest Physicians. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. Sleep. 2003; 26(7):907-13.
8. Yamashiro, Y., et al. CPAP titration for sleep apnea using a split night protocol. Chest. 1995, 107(1):62-66.
9. Flemons WW, Littner MR, Rowley JA, Gay P, Anderson WM, Hudgel DW, McEvoy RD, Loube DI. Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest. 2003; 124(4):1543-79.
10. Rodway GW, Sanders MH.The efficacy of split-night sleep studies. Sleep Med Rev. 2003; 7(5):391-401.

B. Polysomnography (Children):

1. Marcus CI, et al. Respiratory sleep studies in children. Establishment of normative data and polysomnographic predictors of morbidity. Am J Resp Crit Care Med. 1999, 160:1381-1387.
2. Marcus CL, et al. Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002; 109(4):704-12.
3. Schechter MS; Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002; 109(4):e69.
4. Sterni LM, Tunkel DE. Obstructive sleep apnea in children: an update. Pediatr Clin North Am. 2003; 50(2):427-43.
5. Carroll JL. Obstructive sleep-disordered breathing in children: new controversies, new directions. Clin Chest Med. 2003; 24(2):261-82.
6. Kotagal S. Sleep disorders in childhood. Neurol Clin. 2003; 21(4):961-81.
7. D'Andrea LA. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Pediatr Clin North Am. 2004; 51(1):169-86.
8. Rosen CL. Obstructive sleep apnea syndrome in children: controversies in diagnosis and treatment. Pediatr Clin North Am. 2004; 51(1):153-67.
   

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. National Coverage Determination for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA). NCD #240.4. Effective April 4, 2005. Available at: http://www.cms.hhs.gov. Or http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd#PP. Accessed on: August 6, 2006.
2. Hayes, Inc. Hayes Medical Technology Directory. Sleep Apnea Diagnosis, Pediatric. Lansdale, PA: Hayes, Inc; April 21, 2000.  Search updated August 16, 2004.
3. Hayes, Inc. Hayes Medical Technology Directory. Sleep Apnea Diagnosis, Adult. Lansdale, PA: Hayes, Inc; July 15, 1999.  Search updated February 11, 2004.
   

Polysomnography
Sleep Studies
Sleep Testing

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