Medical Policy

This document addresses selected services for the diagnosis of sleep disorders including:

• “Nap” studies
• Actigraphy, including use of static charge sensitive beds
• Diagnostic audio recording, with or without pulse oximetry to document sleep apnea
• Topographic brain mapping
• Acoustic pharyngometry

Note: For criteria related to other sleep testing services, refer to applicable guidelines used by the plan.

Investigational and Not Medically Necessary:

“Nap” studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy.

The following diagnostic tests are considered investigational and not medically necessary:

1. Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea;
2. Topographic brain mapping;
3. Acoustic pharyngometry (Eccovision^™ Acoustic Pharyngometer^®);
4. Actigraphy or static charge sensitive beds.

The evidence in the medical literature does not support the use of single nap studies. This type of sleep study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory. Wide deviations in the conditions and data collection methods available cause significant variability in the outcomes of these studies and do not allow for proper sleep assessment. Additionally, nap sleep is not physiologically the same as nighttime sleep and does not adequately reflect the range of sleep phases required for proper diagnosis, therefore, results are not accurate when compared to the current standard of a full polysomnography (PSG).

While the use of actigraphy has been demonstrated to be useful in the detection of sleep problems in “healthy” or normal individuals, potential benefits for individuals with suspected sleep disorders have not been shown. The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy.

The potential benefits of diagnostic audio recording, used alone or in conjunction with pulse oximetry, have not been demonstrated to provide clinical benefits equivalent to PSG. While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis.

The Eccovision Acoustic Pharyngometer (Hood Laboratories; Pembroke, MA) is a noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection. Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA. In addition, studies have suggested that acoustic pharyngometry may be useful in identifying sites of airway narrowing. However, the utility of acoustic pharyngometry measurement in the clinical setting of OSA has not been demonstrated, and it remains unclear how this test will impact treatment planning and clinical outcomes.

Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA. However, the evidence is limited to small case series studies that do not allow adequate evaluation of this technology. At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations.

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 (QOL), productivity, and overall health. There are many different types of sleep-related disorders, including obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), 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).

Sleep disorder studies are used to determine or confirm a diagnosis related to sleep disturbances. These tests vary in the number and nature of sleep parameters that are measured, in order to gain an understanding of the conditions under which sleep disturbances occur. OSA represents a very common diagnosis within the spectrum of sleep disorders and is the focus of this document. 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 OSA and is not addressed in this document.

Many portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders. These tests include, but are not limited, to: “nap studies,” actigraphy, diagnostic audio-taping, topographic brain mapping, and acoustic pharyngometry. However, none of these portable tests currently provide diagnostic information that is superior to established Type III home portable monitors (HPM), which monitor and record a minimum of four parameters: respiratory movement/effort, airflow, ECG/heart rate, and oxygen saturation.

Acoustic Pharyngometer (Eccovision): This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency. The technique is based on the analysis of sound waves that are launched from a loudspeaker and travel along a wave tube into the subject’s airways where they are reflected. Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels.

Actigraphy: This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subject’s movement over a period of time. Measurements usually involve the detection of wrist movements.

Airflow and respiratory effort in conjunction with oxygen saturation: These terms are translated into the standard measures of apneic-hypopneic index (AHI) or respiratory disturbance index (RDI). Oxygen saturation measures the significance of respiratory events.

Apnea: A transient period where breathing ceases.

Apnea-Hypopnea index (AHI) or Respiratory disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use. An AHI/RDI greater than 30 is consistent with severe OSA. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.

Continuous positive airway pressure (CPAP): This is a noninvasive treatment for OSA that involves delivery of pressurized air during sleep through a device that snugly covers the nose. The appropriate setting for standard CPAP treatment is determined during a titration sleep study.

Epworth sleepiness scale (ESS): A standardized measure of the degree of sleepiness.

Excessive daytime sleepiness: This refers to a condition where a person feels very drowsy during the day, even after getting adequate nighttime rest, and has a tendency to fall asleep or requires extra effort to avoid sleeping in inappropriate situations, such as at work or driving. This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale.

Home/Portable sleep study: A diagnostic test proposed for home use which may be self-administered or attended by a technician. The machine is returned to the doctor the following morning for data analysis.

Hypopnea: Breathing that is more shallow, and/or slower, than normal.

Nap study: This term refers to a shorter daytime version of a PSG sleep study.

Narcolepsy: This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy).

Obstructive sleep apnea (OSA): This is a form of sleep disturbance, which occurs as the result of a physical occlusion of the upper airway during sleep, which interferes with normal breathing. The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway. This condition is associated with frequent awakening and often with daytime sleepiness.

Sleep disorder: A disruptive pattern of sleep that may include difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep.

Upper airway: The area of the upper respiratory system including the nose, mouth and throat.

The following codes for treatments and procedures applicable to this document 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.

When services are Investigational and Not Medically Necessary:

Peer Reviewed Publications:

1. Conley S, Knies A, Batten J, et al. Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: a systematic review and meta-analysis. Sleep Med Rev. 2019; 46:151-160.
2. D'Andrea LA. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Pediatr Clin North Am. 2004; 51(1):169-186.
3. Flemons WW. Clinical practice. Obstructive sleep apnea. N Engl J Med. 2002; 347(7):498-504.
4. Guilleminault C, Abad VC. Obstructive sleep apnea syndromes. Med Clin North Am. 2004; 8(3):611-630.
5. Hyde M, O'Driscoll DM, Binette S, et al. Validation of actigraphy for determining sleep and wake in children with sleep disordered breathing. J Sleep Res. 2007; 16(2):213-216.
6. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Otolaryngol Head Neck Surg. 2004; 130(1):58-66.
7. Levenson JC, Troxel WM, Begley A, et al. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. J Clin Sleep Med. 2013; 9(2):125-131.
8. Marino M, Li Y, Rueschman MN, et al. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Sleep. 2013; 36(11):1747-1755.
9. Monahan KJ, Larkin EK, Rosen CL, et al. Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. Am J Respir Crit Care Med. 2002; 165(11):1499-1503.
10. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med. 2007; 146(3):157-166.
11. O'Driscoll DM, Foster AM, Davey MJ, et al. Can actigraphy measure sleep fragmentation in children? Arch Dis Child. 2010; 95(12):1031-1033.
12. Strollo PJ Jr. Indications for treatment of obstructive sleep apnea in adults. Clin Chest Med. 2003, 24(2):307-313.
13. Werner H, Molinari L, Guyer C, Jenni OG. Agreement rates between actigraphy, diary, and questionnaire for children's sleep patterns. Arch Pediatr Adolesc Med. 2008; 162(4):350-358.
14. Westbrook PR, Levendowski DJ, Cvetinovic M, et al. Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home. Chest. 2005; 128(4):2166-2175.
15. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004; 291(16):2013-2016.
16. Yavuz-Kodat E, Reynaud E, Geoffray MM, et al. Validity of actigraphy compared to polysomnography for sleep assessment in children with autism spectrum disorder. Front Psychiatry. 2019; 10:551.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Berry RB, Quan SF, Abreu AR, et al. for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.6. Darien, IL: AASM; 2020.
2. Centers for Medicare and Medicaid Services. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. NCD #240.4.1. Effective March 3, 2009. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&. Accessed on November 13, 2023.
3. Collop NA, Anderson WM, Boehlecke B, et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007; 3(7):737-747.
4. Collop NA, Tracy SL, Kapur V, et al. American Academy of Sleep Medicine (AASM). Obstructive Sleep apnea Devices for Out-Of-Center (OOC) testing: Technology Evaluation. J Clin Sleep Med. 2011; 7(5):531-548.
5. Flemons WW, Littner MR, Rowley JA, et al. 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):1543-1579.
6. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Westchester, IL: American Academy of Sleep Medicine; 2007.
7. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017; 13(3):479–504.
8. Kirk V, Baughn J, D'Andrea L, et al. American Academy of Sleep Medicine Position Paper for the Use of a Home Sleep Apnea Test for the Diagnosis of OSA in Children. J Clin Sleep Med. 2017; 13(10):1199-1203.
9. Littner M, Hirshkowitz M, Kramer M, et al. American Academy of Sleep Medicine; Standards of Practice Committee. Practice parameters for using polysomnography to evaluate insomnia: an update. Sleep. 2003; 26(6):754-760.
10. Marcus CL, Brooks LJ, Draper KA, et al. American Academy of Pediatrics (AAP). Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012; 130(3):576-584.
11. Mysliwiec V, Martin JL, Ulmer CS, et al. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Annals Intern Med. 2020; 172(5):325-336.
12. Smith MM, McCrae CC, Cheung JJ, et al. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med, 2018; 14(7):1231-1237.
13. Thurnheer R, Bloch KE, Laube I, et al.; Swiss Respiratory Polygraphy Registry. Respiratory polygraphy in sleep apnea diagnosis. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. Swiss Med Wkly. 2007; 137(5-6):97-102.
14. Trikalinos TA, Ip S, Raman G, et al. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. AHRQ Technology Assessment Program. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007.

1. American Academy of Sleep Medicine. Sleep education. Sleep Apnea. Available at: https://aasm.org/aasm-introduces-new-patient-education-website-sleepeducation-com/. Accessed on November 13, 2023.

Actigraphy
Acoustic Pharyngometry
Apnea/Hypopnea Index (AHI)
Apnea Risk Evaluation System (ARES^™)
Nap Study
Obstructive Sleep Apnea (OSA)
Quantitative EEG Mapping
SleepStrip^® II (S.L.P. Ltd.; Israel)
SNAP Testing System (Snap Diagnostics, LLC; Vernon Hills, IL)
Static Charge Sensitive Beds
Topographic EEG Mapping

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Applicable to Commercial HMO members in California: When a medical policy states a procedure or treatment is investigational, PMGs should not approve or deny the request. Instead, please fax the request to Anthem Blue Cross Grievance and Appeals at fax # 818-234-2767 or 818-234-3824. For questions, call G&A at 1-800-365-0609 and ask to speak with the Investigational Review Nurse.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only – American Medical Association