Auto-adjusting positive airway pressure (APAP) may be considered medically necessary for the titration of pressure in individuals with clinically significant obstructive sleep apnea (OSA) defined as those who have:
An Apnea/Hypopnea Index (AHI), Respiratory Disturbance Index (RDI), or Respiratory Event Index (REI) of at least 15 events per hour, OR
An AHI, RDI, or REI 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); OR
If there is a significant change in weight or change in symptoms suggesting that continuous positive airway pressure (CPAP) should be retitrated or possibly discontinued.
CPAP may be considered medically necessary in adult or pediatric individuals with clinically significant OSA.
Clinically significant OSA in adults is:
An AHI, RDI, or REI ≥15, OR
An AHI, RDI, or REI ≥5 in an individual with 1 or more signs or symptoms associated with OSA (e.g., excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke).
Clinically significant OSA in pediatric individuals is:
An AHI or RDI ≥5 OR
An AHI or RDI ≥1.5 in an individual with excessive daytime sleepiness, behavioral problems or hyperactivity.
Bilevel positive airway pressure (PAP) or APAP may be considered medically necessary in individuals with clinically significant OSA who have failed a prior trial of CPAP or for whom bilevel PAP is found to be more effective in the sleep lab.
Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adults with clinically significant OSA under the following conditions:
OSA, defined by an AHI, RDI, or REI of at least 15 events per hour or an AHI, RDI, or REI of at least 5 events per hour in an individual with 1 or more signs or symptoms associated with OSA (e.g., excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke), AND
A trial with CPAP has failed or is contraindicated, AND
The device is prescribed by a treating physician, AND
The device is custom-fitted by qualified dental personnel, AND
There is absence of temporomandibular dysfunction or periodontal disease.
Note: CPAP has been shown to have greater effectiveness than oral appliances in general. This difference in efficacy is more pronounced for individuals with severe OSA, because oral appliances have been shown to be less efficacious in individuals with severe OSA than in individuals with mild-to-moderate OSA. Therefore, it is particularly important that individuals with severe OSA have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance.
The use of CPAP, bi-level PAP, APAP, and intraoral appliances that do not meet the above criteria is considered investigational for the treatment of OSA.
The use of an abbreviated daytime sleep session for acclimation to CPAP (PAP-NAP) is considered investigational.
The use of a sleep positioning trainer with vibration is considered investigational for the treatment of positional OSA.
The use of daytime electrical stimulation of the tongue is considered investigational for the treatment of OSA.
Palate and mandible expansion devices are considered investigational for the treatment of OSA.
Nasal expiratory positive airway pressure (EPAP) and oral pressure therapy devices are considered investigational.
