Parasomnia - Sleep disorder

Parasomnia. -- Parasomnias are a group of disorders during sleep that are associated with brief or partial arousals but not with marked sleep disruption or impaired daytime alertness. The presenting complaint is usually related to the behavior itself. Most parasomnias are more common in children, but may persist into adulthood when their occurrence may have more pathologic significance. Behavior during these times can often lead to damage to the patient's surroundings and injury to the patient or to others.

Parasomnias include the following conditions: confusion arousals, sleepwalking (Somnambulism), sleep terrors, REM sleep behavior disorder, sleep-related epilepsy, sleep bruxism, sleep enuresis, and miscellaneous (nocturnal headbanging, sleep talking, restless leg syndrome, periodic limb movement disorder, and nocturnal leg cramps).

Some of the more common, uncomplicated, noninjurious parasomnias, such as typical disorders of arousal, nightmares, enuresis, somniloquy, and bruxism can usually be diagnosed by clinical evaluation alone. A clinical history, neurologic exam and routine EEG obtained while the patient is awake and asleep are often sufficient to establish the diagnosis and permit the appropriate treatment of sleep related epilepsy.

Polysomnography, including video recording and additional EEG channels in an extended bilateral montage, is routinely indicated to assist with the diagnosis of paroxysmal arousals or other sleep disruptions that are thought to be seizure related when the initial clinical evaluation and results of a standard EEG are inconclusive. Polysomnography is not routinely indicated for patients with epilepsy who have no specific symptoms consistent with a sleep disorder.

Polysomnography is indicated to provide a diagnostic classification or prognosis when both of the following exist: the clinical evaluation and results of standard EEG have not demonstrated a seizure disorder; and there is a history of repeated violent or injurious episodes during sleep. Normally when polysomnography is performed for the diagnosis of parasomnias, the following measurements are obtained: sleep-scoring channels (EEG, EOG, chin EMG); EEG using an expanded bilateral montage; EMG for body movements; and audio-video recording and documented technologist observations

Coverage Limitations for Sleep Disorder Testing

Coverage Limitations for Sleep Disorder Testing

Diagnostic testing that is duplicative of previous sleep testing, to the extent the results are still pertinent, is not covered if there have been no significant clinical changes in medical history since the previous study.

Polysomnography, cardiorespiratory sleep studies, and MSLTs are not covered in the following situations:

• For the diagnosis of patients with chronic insomnia;
• To preoperatively evaluate a patient undergoing a laser assisted uvulopalato-pharyngoplasty without clinical evidence that obstructive sleep apnea is suspected;
• To diagnose chronic lung disease (Nocturnal hypoxemia in patients with chronic, obstructive, restrictive, or reactive lung disease is usually adequately evaluated by oximetry. However, if the patient’s symptoms suggest a diagnosis of obstructive sleep apnea, polysomnography is considered medically necessary);
• In cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated;
• For patients with epilepsy who have no specific complaints consistent with a sleep disorder;
• For patients with symptoms suggestive of the periodic limb movement disorder or restless leg syndrome unless symptoms are suspected to be related to a covered indication.

CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:

• PSG performed in a sleep laboratory; or
• unattended home sleep monitoring device of type II; or
• unattended home sleep monitoring device of type III; or
• unattended home sleep monitoring device of type IV, measuring at least 3 channels

Screening tests, in the absence of associated signs, symptoms or complaints will be denied.

Medicare coverage for home sleep testing

HOME SLEEP TESTING

Effective for dates of service on or after March 13, 2008, Medicare will allow for coverage of CPAP therapy based upon a diagnosis of OSA by home sleep testing.

Performance of home sleep testing is limited to FDA approved devices furnished with adequate patient instruction and support to assure successful completion and reliable results. Provision of the device, patient instruction and support can be provided by sleep centers, physicians, and Independent Diagnostic Testing Facilities who can demonstrate use of FDA approved devices, inspection of the devices, and the patient education and support necessary.

The professional services related to home sleep testing (G0398, G0399, and G0400) are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patient’s condition, meets all Medicare requirements, and the physician who performs the service has sufficient training and experience to reliably perform the service.

Home Sleep Testing is not reasonable and therefore not covered for patients with comorbidities (moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure), other sleep disorders (central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders or narcolepsy), or for screening asymptomatic patients.

Narcolepsy. - Sleep disorder

Sleep disorder testing performed during the acute phase of an illness or injury is not appropriate.

Narcolepsy. -- Narcolepsy is a neurologic disorder of unknown etiology characterized predominantly by abnormalities of REM, some abnormalities of NREM sleep and the presence of excessive daytime sleepiness often with involuntary daytime sleep episodes. Other associated symptoms of narcolepsy include cataplexy and other REM sleep phenomena, such as sleep paralysis and hypnogogic hallucinations.

Related diagnostic testing is covered if the patient has inappropriate sleep episodes or attacks (e.g., while driving, in the middle of a meal, in the middle of a conversation), amnesiac episodes or continuous disabling drowsiness. The sleep disorder clinic must maintain documentation that this condition is severe enough to interfere with the patient's well-being and health.

The diagnosis of narcolepsy is usually confirmed by overnight polysomnography followed by a multiple sleep latency test (MSLT) the next day. The following measurements are normally required to diagnose narcolepsy:

1. PSG assessment of the quality and quantity of night-time sleep;
2. Mean sleep latency of 8 minutes or less for 4 or more naps in the MSLT; and
3. The presence of two or more sleep-onset REM periods during the MSLT.

Repeat polysomnography may be indicated if the initial PSG and MSLT fail to identify narcolespy when:

1. The first study is technically inadequate due to equipment failure;
2. The patient could not sleep or slept for a insufficient amount of time to determine a clinical diagnosis;
3. The initiation of therapy or confirmation of the efficacy of prescribed therapy is clinically needed; or
4. The results were inconclusive.

Sleep apnea and diagnosis method

Sleep Apnea. -- Sleep Apnea is a respiratory dysfunction resulting in cessation or near cessation of respiration during sleep. These cessations of breathing may be due to either an occlusion of the airway (obstructive sleep apnea), absence of respiratory effort (central sleep apnea), or a combination of these factors (mixed sleep apnea). Central sleep apnea is a relatively rare entity. Obstructive sleep apnea (OSA) is caused by one of the following: (1) reduced upper airway caliber due to obesity, adenotonsillar hypertrophy, mandibular deficiency, macroglossia, or upper airway tumor; (2) excessive pressure across the collapsible segment of the upper airway; or (3) activity of the muscles of the upper airway insufficient to maintain patency.

The diagnosis of sleep apnea may be made using the following modalities:

1. Polysomnography (PSG) performed in a sleep laboratory; or
2. unattended home sleep monitoring device of type II; or
3. unattended home sleep monitoring device of type III; or
4. unattended home sleep monitoring device of type IV, measuring at least 3 channels (CAG-00093R2)

A positive test for obstructive sleep apnea (OSA) is established if either of the following criteria using the Apnea-Hypopnea Index (AHI) or Respiratory Distress Index (RDI) are met:

• AHI or RDI greater than or equal to 15 events per hour, or
• AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition; mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.

If the AHI or RDI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a 2 hour period (CAG-00093R2).

CPAP is a non-invasive technique for providing single levels of air pressure from a flow generator, via a nose mask. The purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in OSA.

For patients with severe and unambiguous obstructive sleep apnea, the initiation of treatment with nasal CPAP may be incorporated into the diagnostic study night. A “split-night” study (initial diagnostic PSG followed by CPAP Titration during PSG on the same night) may be an alternative to one full night of diagnostic PSG followed by a second night of Titration as long as:

• CPAP Titration is carried out for more than 3 hrs, and
• PSG documents that CPAP significantly improves patient respiration during sleep.

The use of CPAP devices is covered under Medicare when ordered and prescribed by the licensed treating physician to be used in adult patients with OSA if either of the criteria noted above are met.

Documentation supporting a diagnosis of OSA must be available upon request by Medicare.

Repeat PSG for diagnosing sleep apnea requires documentation justifying the medical necessity for the repeat test.

Repeat PSG may be indicated:

1. If the first study is technically inadequate due to equipment failure;
2. If the patient could not sleep or slept for an insufficient amount of time to determine a clinical diagnosis;
3. If initiation of therapy or confirmation of the efficacy of prescribed therapy is clinically needed; or
4. If the results were inconclusive.

The supplier of CPAP must conduct education of the beneficiary prior to the use of the CPAP device to ensure that the beneficiary has been educated in the proper use of the device. A caregiver, for example a family member, may be compensatory, if consistently available in the beneficiary's home and willing and able to safely operate the CPAP device.

Follow up polysomnography is indicated for any of the following:

• to evaluate the response to treatment (CPAP, oral appliances, surgical intervention);
• after substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure;
• after substantial weight gain has occurred in patients previously treated with CPAP successfully, who are again symptomatic despite the continued use of CPAP, to ascertain whether pressure adjustments are needed;
• when clinical response is insufficient or when symptoms return despite a documented good initial response to treatment with CPAP; or
• when there has been a significant change in cardiorespiratory status, such as the development or worsening of CHF or LV dysfunction.