A single unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone (PAT), oximetry, and actigraphy may be considered medically necessary in adults who are at high-risk for obstructive sleep apnea (OSA) and have no evidence of a health condition that might alter ventilation or require alternative treatment (ie, central sleep apnea, heart failure, chronic pulmonary disease, obesity hypoventilation syndrome, neuromuscular disorders with sleep-related symptoms, injurious or potentially injurious parasomnias, or narcolepsy). The Policy Guidelines section defines high pretest probability.
A single unattended (unsupervised) home sleep apnea test with a minimum of recording channels as described above, may be considered medically necessary as a screening tool in individuals who are scheduled for bariatric surgery and have no evidence of a health condition that might alter ventilation or require alternative treatment (see Policy Guidelines section).
Unattended home sleep studies are considered investigational in children (<18 years of age). Repeated unattended (unsupervised) home sleep apnea test with a minimum of 3 recording channels with the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively PAT, oximetry, and actigraphy, may be considered medically necessary in adults under the following circumstances: To assess efficacy of surgery or oral appliances or devices; OR To reevaluate the diagnosis of OSA and need for continuous positive airway pressure (CPAP) (eg, if there is a significant change in weight or change in symptoms suggesting that CPAP should be retitrated or possibly discontinued). Supervised polysomnography (PSG) performed in a sleep laboratory may be considered medically necessary in individuals with a moderate or high pretest probability of OSA in the following situations: Pediatric individuals (ie, <18 years of age); OR When individuals do not meet criteria for an unattended home sleep apnea test as described above; OR A previous home study failed to establish the diagnosis of OSA in an individual with a high pretest probability of OSA; OR A previous home study was technically inadequate; OR Failure of resolution of symptoms or recurrence of symptoms during treatment; OR When testing is done to rule out other sleep disorders such as central sleep apnea, injurious or potentially injurious parasomnias, or narcolepsy (see evidence review 2.01.99); OR Presence of a comorbidity that might alter ventilation or decrease the accuracy of a home sleep apnea test, including, but not limited to heart failure, neuromuscular disease, chronic pulmonary disease, or obesity hypoventilation syndrome. A repeated, supervised PSG performed in a sleep laboratory may be considered medically necessary in individuals who meet the criteria above for an in-laboratory PSG under the following circumstances: To initiate and titrate CPAP in adults who have: An Apnea/Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of at least 15 events per hour, OR An AHI or RDI of at least 5 events per hour in an individual with 1 or more signs or symptoms associated with OSA (eg, excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke); Note: A split-night study, in which moderate-to-severe OSA is documented during the first portion of the study using PSG, followed by CPAP during the second portion of the study, can eliminate the need for a second study to titrate CPAP (see Policy Guidelines section for criteria to perform a split-night study). To initiate and titrate CPAP in children: In pediatric individuals, an AHI or RDI of ≥5; OR An AHI or RDI ≥1.5 in an individual with excessive daytime sleepiness, behavioral problems, or hyperactivity. To assess efficacy of surgery (including adenotonsillectomy) or oral appliances/devices. Supervised or unattended home sleep apnea tests that do not meet the above criteria are considered investigational. Multiple sleep latency testing is considered investigational in the diagnosis of OSA.
