Compliance Corner: Review of Commercial Treatment Medical Policy for Obstructive Sleep Apnea

I recently have been receiving questions on the hypopnea scoring criteria to use for qualification of positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA). The questions seem to be focused on commercial plans available for Medicare replacement plans and Aetna commercial plans; however, I have to stress that there needs to be an understanding of the treatment of OSA criteria for all of our patients' plans. Durable medical equipment (DME) companies are already experiencing delays in fulfilling PAP orders due to the national shortage of PAP machines and are experiencing even greater delays in processing orders if therapy is being ordered based on sleep studies using the 3% scoring rule in identifying hypopnea. Unfortunately, it wouldn't matter what DME you send the order to as they should, and likely will be, rejecting it if the patient's insurance plan follows the 4% rule in identifying hypopneas.

To review, the current American Association of Sleep Medicine (AASM) Scoring Manual Version 2.6 defines the scoring of hypopneas in two rules:¹

Rule 1A: Score a respiratory event as a hypopnea if all of the following criteria are met:

1. The peak signal excursions drop by  ≥30% of pre-event baseline using nasal pressure during a diagnostic study or PAP device flow during a titration study, or an alternative hypopnea sensor
2. The duration of the ≥30% drop in signal excursion is ≥10 seconds
3. There is a  ≥3% oxygen desaturation from pre-event baseline or the event is associated with an arousal.

Rule 1B: Score a respiratory event as a hypopnea if all of the following criteria are met:

1. The peak signal excursions drop by  ≥30% of pre-event baseline using nasal pressure during a diagnostic study or PAP device flow during a titration study, or an alternative hypopnea sensor
2. The duration of the ≥30% drop in signal excursion is ≥10 seconds
3. There is a ≥4% oxygen desaturation from pe-event baseline.

The criteria used to score a respiratory event as a hypopnea (rule A or B) should be reported on the sleep study report as the patient's payor will look at this to qualify the patient for PAP therapy.

I have pulled policies and will attempt to summarize the rules used to qualify events by insurer definition below. Here is an example of the guidelines you may see outlined for treatment of OSA:

• Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.²
• The apnea-hypopnea index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour of sleep without the use of a PAP device. Sleep time can only be measured in a Type I (facility-based polysomnogram) or Type II sleep study. Thus, the AHI is reported only in Type I or Type II sleep studies.
• The respiratory disturbance index (RDI) is equal to the episodes of apnea and hypopnea per hour of recording without the use of a PAP device. The RDI is reported in Type III, Type IV and other home sleep studies.³
• Leg movement, snoring, respiratory effort related arousals (RERAs) and other sleep disturbances that may be included by some polysomnographic facilities are not considered to meet the AHI and/or RDI definition in many policies. Although AHI and RDI have been used interchangeably, some facilities use the term RDI to describe a calculation that includes these other sleep disturbances. Requests for PAP devices will be considered not medically necessary if based upon an index that does not score apneas and hypopneas separately from other sleep disturbance events. Only persons with an AHI and/or RDI, as defined in the policy that meet medical necessity criteria may qualify for a PAP device.⁴
• Bilevel positive airway pressure (BiPAP) without a backup rate feature, BiPAP with pressure relief technology (Bi-Flex), DPAP, and variable positive airway pressure (VPAP) are considered medically necessary for members who are intolerant to continuous positive airway pressure (CPAP) or automatic titrating airway pressure (AutoPAP), or for whom CPAP or AutoPAP is ineffective. Ineffective is defined as documented failure to meet therapeutic goals using CPAP or AutoPAP during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings). The records must document that both of the following medical necessity criteria are met:⁴
  • An appropriate interface for the CPAP and AutoPAP has been properly fit, and the member is using it without difficulty; and
  • The current pressure setting of the CPAP or AutoPAP prevents the member from tolerating the therapy and lower pressure settings of the CPAP or AutoPAP were tried but failed to:
    • Adequately control the symptoms of OSA; or
    • Improve sleep quality; or
    • Reduce the AHI/RDI to acceptable levels.
• These alternatives to CPAP may also be considered medically necessary for OSA members with concomitant breathing disorders, which include restrictive thoracic disorders, chronic obstructive pulmonary disease (COPD) and nocturnal hypoventilation.
• An oral pressure appliance (OPAP) is considered medically necessary DME only on an exception basis for members who are unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain or claustrophobia from masks.
• A BiPAP device with a backup rate feature (e.g., adaptive servoventilation, VPAP Adapt SV) is considered experimental and investigational for OSA.⁴
• Replacement of PAP devices is considered medically necessary at the end of their five-year reasonable useful lifetime (RUL). Replacement of these items is considered medically necessary prior to the end of the five-year RUL due to a change in the member's condition. Replacements needed due to misuse or abuse are not covered.⁴ It is important to be mindful of the standard that payers retain the right to review and revise their medical policy guidelines at their sole discretion at any time without prior notice. Your facility compliance officer should regularly check for updates to not only the criteria being used to qualify a patient for a type of diagnostic study but also what needs to be reported to allow patients to be treated.

Below are a few policy links for reference, pulled on May 5, 2022. This list is a representation of the policies in place and not intended to be a complete list.

Insurances Requiring 4% Scoring

• All Medicare Advantage Plans
• Aetna
• Aetna Medicare
• Gateway Medicare (Highmark Wholecare)
• CareCentrix
• Clover
• United Healthcare/Dual Medicare
• Blue Journey CBC Advantage Plan
• FFS Medicare (Traditional Medicare)
• Horizon NJ (CCX)
• Highmark Advantage Plan

References:

1. American Association of Sleep Medicine Scoring Manual Version 2.6. Retrieved from https://aasm.org/clinical-resources/scoring-manual/
2. Centers for Medicare and Medicaid Services. CPAP for Obstructive Sleep Apnea. Retrieved from https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/CPAP
3. Centers for Medicare and Medicaid Services. Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Retrieved from https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33718&ver=20&articleId=52467&NCDId=226&ncdver=3&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7CCAL%7CNCD%7CMEDCAC%7CTA%7CMCD&ArticleType=SAD%7CEd&PolicyType=Both&s=-&AdvSearchName=3%7C9%7C4%7C1%7C7%7C5%7C6%7C2%7C8&KeyWord=positive+airway+pressure&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAACgAEAAAAAAA&
4. Obstructive Sleep Apnea in Adults. Retrieved from http://www.aetna.com/cpb/medical/data/1_99/0004.html