Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 08/03/2011 Title: Obstructive Sleep Apnea (OSA)
Revision Date: 02/01/2019 Document: BI306:00
CPT Code(s): 21198, 21199, 21208, 21209, 21685, 31600, 42145, 95800, 95801, 95803, 95805, 95806-95808, 95810, 95811, 0424T-0436T, E0485, E0486, E0601, G0399
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    The diagnosis and treatment of moderate or severe obstructive sleep apnea (OSA) is covered when medically necessary.

2)    Surgical treatment of OSA requires pre-authorization.

3)    Use of an implantable Neurostimulator device such as the Inspire Upper Airway Stimulator is considered experimental and investigational and is not covered.

4)    Treatment of OSA with Provigil (Modafinil) or Nuvigil (Armodafinil) requires pre-authorization (see BI170). 

5)    Treatment of OSA with other medications is not covered.

6)    The treatment of OSA with Continuous Positive Airway Pressure (CPAP) or oral appliances is covered when medically necessary.

7)    OSA may be diagnosed, in patients with a high pre-test likelihood of OSA, by stand-alone/ambulatory home sleep test (HST) that records at least three channels, including pulse oximetry. Initial stand-alone/ambulatory HST does not require preauthorization but we encourage the use of preferred vendors. QualChoice identifies preferred vendors on the basis of quality, convenience and cost-effectiveness. Depending on the specific plan and benefit structure, the use of preferred vendors may result in reduced member costs. If patients have significant illness such as chronic obstructive pulmonary disease, congestive heart failure, seizure disorder, neuromuscular disease, or specific factors complicating sleep then OSA may be diagnosed (with treatment titration, if needed, the same night) in a sleep laboratory. As with HST, the use of preferred sleep laboratory vendors may result in significant savings for members.

8)    Polysomnography performed in a sleep laboratory will require preauthorization to verify there are significant comorbidities or specific complicating factors. Sleep studies performed more than twice in a calendar year (by HST or in a sleep lab) will require pre-authorization.


Medical Statement

1)    Diagnosis

A.   Use of a home sleep testing device that monitors at least three channels is considered medically necessary for the diagnosis of OSA:

i)     In members with a high probability of OSA who do not have significant comorbidities such as chronic obstructive pulmonary disease, congestive heart failure, seizures or neuromuscular disease.

ii)    Requires interpretation by a sleep specialist.

iii)   Stand-alone/ambulatory HST less than three times per year does not require preauthorization but we encourage the use of preferred vendors. QualChoice identifies preferred vendors on the basis of quality, convenience and cost-effectiveness. Depending on the specific plan and benefit structure, the use of preferred vendors may result in reduced member costs. Stand-alone/ambulatory home sleep testing is generally performed on a single occasion to confirm a clinical impression of OSA. Repeat testing is generally only required if there is a substantial change, such as major weight loss. In any case, home sleep testing will not be covered more than twice per year without preauthorization.

B.   Diagnosis of OSA by sleep study or polysomnography in a sleep lab (including performance of a split night study for titration of CPAP) requires preauthorization.  As with HST, the use of preferred sleep laboratory vendors may result in significant savings for members. Sleep lab testing is considered medically necessary for any of the following:

i)     BMI:

a)    BMI >45, OR

b)    Pulmonary function studies show obesity hypoventilation syndrome, OR

c)    BMI >35 plus arterial blood gas with PCO2 >45, OR

d)    BMI>35 plus inability to lie flat in bed, OR

ii)    Significant comorbidities such as:
a)  Moderate to severe pulmonary disease for example asthma or COPD, OR    

b)    Moderate to severe CHF with documented pulmonary congestion or known left ventricular ejection fraction of <45%, OR

c)    Uncontrolled seizures, OR

d)    Neuromuscular disease, OR

e)    Factors complicating sleep such as narcolepsy, central sleep apnea, periodic limb movement disorder or parasomnias,

C.   Polysomnography can usually diagnose OSA and titrate CPAP within a single night (CPT code 95811 “split night” PSG & titration). If a member meets criteria for sleep lab testing, 95810 OR 95811 will be approved. However, if OSA is not documented, CPAP titration is not needed and 95810 should be billed. Occasionally it may be necessary to do titration on a subsequent night, such as if the patient does not fall asleep early enough to obtain adequate diagnostic information. In these situations, the first night should be billed as 95810 and a separate request will need to be submitted (if clinically indicated) for titration. As with home sleep testing, it may be necessary to repeat polysomnography after a substantial change, such as surgical treatment.

D.  Multiple sleep latency or maintenance of wakefulness testing:

i)   Is not considered medically necessary for the diagnosis or treatment of OSA. 

ii)  Is considered medically necessary for the diagnosis or monitoring of other sleep disorders, such as narcolepsy.

2)    Non-Surgical Treatment

CPAP

A.   A CPAP is considered medically necessary DME for members with a positive facility-based or home sleep test when: 

i)   The sleep study is based on a minimum of 2 hours of continuous recorded sleep, OR

ii)  Shorter periods of continuous recorded sleep if the total number of recorded events during that shorter period is at least the number of events that would have been required in a 2 hour period, AND

iii)   Positivity is defined by the following criteria:

(a)  Strongly positive with member`s Apnea Hypopnea Index (AHI) ≥30 events per hour with a minimum of 60 events

(b)  Moderately positive with member’s AHI ≥ 15 events per hour with a minimum of 30 events; OR 

(c)  Mildly positive with member’s AHI >5 and <15 events per hour with a minimum of 10 events AND at least one of the following is met:

§  Documented history of stroke; OR

§  Documented hypertension (systolic blood pressure >140 mm Hg and/or diastolic blood pressure >90 mm Hg); OR

§  Documented ischemic heart disease; OR

§  Documented symptoms of impaired cognition, mood disorders, or insomnia; OR

§  Excessive daytime sleepiness (documented by Epworth Sleepiness Scale >10); OR

§  >20 episodes of oxygen desaturation (oxygen saturation of <85%) during a full night sleep study, or any one episode of severe oxygen desaturation (oxygen saturation of <70%).  

B.   For patients without significant comorbidities, an auto-titrating CPAP device does not require prior authorization and can be prescribed for home use. CPAP accessories and supplies required for maintaining use of the machine are covered for members who meet criteria for positive airway pressure devices.

ORAL APPLIANCES

A.   Custom-fitted and prefabricated oral appliances to reduce upper airway collapsibility are considered medically necessary for members with OSA who meet the above medical necessity criteria for CPAP and:

i)   A trial with CPAP has failed or is contraindicated, AND

ii)  The device is prescribed by a treating physician, AND

iii)   The device is custom-fitted by qualified dental personnel, AND

iv)   There is absence of temporomandibular dysfunction or periodontal disease.

3)    Surgical Treatment

Surgical Treatment for OSA requires pre-authorization for the following:

a)    Uvulopalatopharyngoplasty (UPPP) – Uvulopalatopharyngoplasty is used to treat OSA by enlarging the oropharynx. It is considered medically necessary for OSA members who:

i)   Meet the criteria for CPAP, AND

ii)  Have failed or who are intolerant to CPAP.

b)    Jaw Realignment Surgery (i.e., hyoid Myotomy and suspension, mandibular osteotomy, genioglossal advancement) – Jaw realignment surgery is considered medically necessary for persons who fail other treatment approaches for OSA.

i)   Note: According to the medical literature, persons undergoing jaw realignment surgery must usually also undergo orthodontic therapy to correct changes in occlusion associated with the surgery. Orthodontic therapy (i.e., the placement of orthodontic brackets and wires) is excluded from coverage under standard QualChoice medical plans regardless of medical necessity. Please check benefit plan descriptions for details. Benefits for orthodontic therapy may be available under the member`s dental plan, if any.

c)    Tracheostomy – Tracheostomy is considered medically necessary for those members with the most severe obstructive sleep apnea not manageable by other interventions. Requests for tracheostomy for OSA are subject to medical review.

d)    All other treatments for OSA are considered experimental and investigational.  This includes use of implantable Neurostimulator.

Codes Used In This BI:

21198

Reconstruct lower jaw segment

21199

Reconstruct lower jaw w/advance

21208

Augmentation of facial bones

21209

Reduction of facial bones

21685

Hyoid Myotomy & suspension

31600

Incision of windpipe

42145

Repair palate pharynx/uvula

95800

Sleep study unattended

95801

Sleep study unattended w/analysis

95803

Actigraphy testing

95805

Multiple sleep latency test

95806

Sleep study unattended & resp efft

95807

Sleep study attended

95808

Polysomnography 1-3

95810

Polysomnography 4 or more

95811

Polysomnography w/CPAP titration

0424T

Insrtn/rplcmt of neurostm syst for trmt of ctrl sleep apnea; compl syst

0425T

Insrtn/rplcmt of neurostm syst for trmt of ctrl sleep apnea; sensing lead only

0426T

Insrtn/rplcmt of neurostm syst for trmt of ctrl sleep apnea; stimul lead only

0427T

Insrtn/rplcmt of neurostm syst for trmt of ctrl sleep apnea; pulse gen only

0428T

Rmvl of neurostm syst for trmt of ctrl sleep apnea; pulse gen only

0429T

Rmvl of neurostm syst for trmt of ctrl sleep apnea; sensing lead only

0430T

Rmvl of neurostm syst for trmt of ctrl sleep apnea; stimulation lead only

0431T

Rmvl & rplcmt of neurostm syst for trmt of ctrl sleep apnea, pulse gen only

0432T

Repstn of neurostm syst for trmt of ctrl sleep apnea, stim lead only

0433T

Repstn of neurostm syst for trmt of ctrl sleep apnea, sensing lead only

0434T

Interrogation dvc eval implntd neurostm pulse gen syst for ctrl sleep apnea

0435T

Prgrm dvc eval of implntd neurostm pulse gen syst for ctrl sleep apnea; sgl session

0436T

Prgrm dvc eval of implntd neurostm pulse gen syst for ctrl sleep apnea; dur sleep study

E0485

Oral dvc/appl used to reduce upper airway collapsibility, adjust or non-adjust, prefab,

incl fitting & adjstmt

E0486

Oral dvc/appl used to reduce upper airway collapsibility, adjust or non-adjust,

custom fabr, incl fitting & adjstmt

E0601

Continuous Positive Airway Pressure (CPAP) device

G0399

 

Home sleep study, unattended. Type III prtble monitor, min 4 channels, 2 resp mvmt/airflow, 1 ECG/HR, 1 O2 sat


Limits

1)    The treatment of snoring alone is not considered medically necessary and is not covered.

2)    Diagnosis

a)    Sleep testing will not be covered on consecutive nights.

b)    Normally (per CMS guidelines), 95811 (split night PSG study followed by CPAP titration) can be performed in one night.  If 95811 titration cannot be completed in one night, it should be billed as 95810.  A separate request/approval would then be needed (with positive results from 95810 provided) for completion of CPAP titration (95811) and that would need to be scheduled for a subsequent night.   Requests for simultaneous approval of both 95810 AND 95811 will not be approved since most of the time this will be redundant and not medically necessary.  If 95810 and 95811 are performed on the same or consecutive nights, only 95811 will be allowed.

c)    Sleep testing will not be covered more often than twice in 12 months.

d)    HST not performed by a Joint Commission accredited ambulatory Independent Diagnostic Testing Facility (IDTF) will not be covered.

e)    Actigraphy alone for the diagnosis of OSA is considered experimental and investigational and is not covered.

f)     Respiratory Disturbance Index (RDI) adds other (non-obstructive, “respiratory effort related arousal”) causes of sleep disruption to the AHI.  Because of this, RDI cannot be used instead of AHI to diagnose OSA and need for treatment.

g)     The use of home sleep testing devices that monitor fewer than three channels or that relies on recording of snoring is considered experimental and investigational and is not covered.

h)   Other techniques for diagnosis of OSA, including but not limited to sonography, static charge sensitive beds, cephalography, and laryngeal function studies, are considered experimental and investigational.

3)    Treatment

a)    DME payment may be subject to plan limitations.

b)    Laser-assisted uvulopalatoplasty (LAUPP) is considered experimental and investigational for treatment of OSA.

c)    CPAP is not considered medically necessary for the treatment of upper airway resistance syndrome (UARS). 

d)    Oral appliances to reduce upper airway collapsibility are considered experimental and investigational for indications other than OSA. 

e)    QualChoice considers UPPP experimental and investigational for persons who do not respond to CPAP because this surgical approach has not been shown to be effective in non-obstructive apnea.


Background

Obstructive sleep apnea (OSA) is a syndrome characterized by repetitive upper airway closure during sleep resulting in repeated reversible blood oxygen desaturation and fragmented sleep.  Besides causing excessive daytime sleepiness and fatigue, OSA has been associated with a range of pathophysiological changes that im­pair cardiovascular function, including increased blood inflam­matory markers and repeated rises in blood pressure during sleep. There is increasing evidence that OSA promotes the develop­ment of hypertension, stroke, myocardial infarction, and prema­ture death.  Community based studies suggest that moderate to severe OSA increases the risk of all-cause mortality (hazard ratios 3.0-6.24), largely but not entirely because of increased cardiovascular risk.  This mortality risk is at least partially offset by treatment with CPAP.  Because obesity is a major risk factor for OSA, the prevalence of OSA is increasing in the United States.  Current estimates are that 2-4% of the adult population suffers from OSA.  Certain populations have much higher prevalence; approximately 30% of commercial truckers have at least moderate OSA.

Data from the history and physical examination have been shown to be sensitive but not specific for diagnosing OSA.  The following signs and symptoms may suggest significant risk for OSA: reported apneas by sleep partner; awakening with choking; intense snoring; severe daytime sleepiness, especially with impairment of driving; obesity (body mass index [BMI] greater than or equal to 30); large neck circumference; and hypertension.

Diagnostic tests for OSA can be classified into 4 types.  The most comprehensive type is Type I: attended, or in-facility polysomnography (PSG), also called nocturnal polysomnography (NPSG). There are 3 categories of portable monitors (used in both attended and unattended settings).  Type II monitors have a minimum of 7 channels (e.g., electroencephalogram (EEG), electrooculogram (EOG), electromyogram (EMG), electrocardiogram (ECG), heart rate, airflow, respiratory effort, oxygen saturation). Type III monitors has a minimum of 4 monitored channels including ventilation or airflow (at least 2 channels of respiratory movement or respiratory movement and airflow), heart rate or ECG, and oxygen saturation. Type IV is all other monitors that fail to fulfill criteria for type III monitors. Type IV monitors are split into two subgroups: those assessing three or more bio parameters including pulse oximetry (IV(A)--most newer monitors fall here) and those assessing one or two bio parameters (the original ASDA level IV category, now called IV(B)). NPSG is considered the definitive test for OSA and other sleep disorders. Type II, III, and IV(A) monitors have been used in the home (unattended) setting, and show adequate sensitivity and specificity for diagnosing OSA in that setting when used for patients with high pre-test probability. The sensitivity and specificity of IV (B) monitors in the home are less robust. Home sleep testing is not appropriate for diagnosis of sleep disorders other than OSA. It is expected that members receive lifestyle advice where applicable (i.e., helping people to lose weight, stop smoking and/or decrease alcohol consumption), as these interventions may be adequate to resolve symptoms.

Patients with OSA suffer from numerous apneic events while sleeping, due to collapse of the upper airway during inspiration. Continuous positive airway pressure, and more recently, BiPAP, DPAP, VPAP, and AutoPAP, have been used in the treatment of OSA as a means of serving as a "pneumatic splint" in order to prop open the airways during inspiration. Use of CPAP may require titration in a sleep lab. This titration can be accomplished in a separate overnight session, or, as a more economical and convenient method, in a split-night study on the same night that the diagnosis of OSA is confirmed. Alternatively, for patients with OSA and without other sleep disorders, self-titrating CPAP (AutoPAP) can be prescribed and is usually well tolerated. Long term adherence to CPAP therapy was initially reported to range from 65-80% (Nino-Murcia, et al., 1989; Waldhorn, et al., 1990; Rolfe, et al., 1991; Hoffstein, et al., 1992) with 8-15% of patients refusing to accept treatment (Waldhorn, 1990; Krieger, 1992) after a single night`s use. More recent studies have shown up to 80% of patients falling into the category of regular users (Pepin, et al., 1999).

A variety of oral appliances and prostheses, including tongue retainers and mandibular advancing devices, have been used to treat patients with OSA. These devices modify the airway by changing the posture of the mandible and tongue. A task force of the Standards of Practice Committee of the ASDA concluded that, despite the considerable variation in the design of these devices, their clinical effects in improving OSA have been consistent (Kushida, et al., 2006). These devices have been shown to be effective in alleviating OSA, and present a useful alternative to CPAP or surgery (Ferguson, et al. 2006; Gotsopoulos, et al., 2002). Oral appliances, however, have been shown to be less reliable and effective than CPAP, and therefore the literature suggests that their use should generally be reserved for patients who are intolerant of CPAP. Oral appliances can be prefabricated or custom fabricated. There is evidence of the efficacy of both prefabricated and custom-fabricated appliances for obstructive sleep apnea (Vanderveken, et al., 2008; Henke, et al., 2000).

While virtually all studies report that surgical treatment of OSA improves snoring and daytime sleepiness, improvements in objective outcomes have been inconsistent, and some patients will continue to require CPAP even after surgical treatment. Fujita is credited with developing the UPPP as a method of enlarging the oropharynx (Fujita, et al., 1985). He based the UPPP on his observation that patients with OSA, without other obvious sites of obstruction, often have a large edematous uvula, wide posterior tonsillar pillar mucosa, and redundant mucosal folds in the lateral posterior pharyngeal walls extending from the nasopharynx to the hypopharynx. The surgery attempts to remove the redundant tissue but preserve the underlying muscular layer. In brief, the mucosa and submucosa of the soft palate, tonsillar fossa and the lateral aspect of the uvula are resected. The posterior pillar may be resected if contributing to the narrowing. In essence the amount of tissue removed is individualized for each patient, determined by the potential space and the width of the tonsillar pillar mucosa between the two palatal arches (Fujita, et al., 1985). The UPPP enlarges the oropharynx but cannot correct obstructions in the hypopharynx. Early on it was recognized that UPPP failed in about 50% of unselected patients with OSA. Uvulopalatopharyngoplasty has been found to be most reliably effective in OSA patients who have adequately responded to a trial of CPAP. If CPAP is unsuccessful in relieving a patient’s symptoms, this suggests that apnea is not due to obstruction. Riley, et al. (1990) proposed that these failures may have been caused by an obstruction at the base of the tongue. The surgical approach to this problem has been to either modify the tongue itself or reposition the tongue by repositioning the mandible and/or maxilla. 

A small randomized controlled trial (n=45) with 8 months of follow-up evaluated laser-assisted uvulopalatoplasty (LAUPP) versus no treatment for mild OSA. Although patients who underwent an average of 2.4 LAUPP procedures had statistically significant improvements in snoring and apnea-hypopnea index relative to the control group, improvements in daytime sleepiness and sleep apnea quality of life (QOL) scores were not statistically significant. Moreover, the benefits of LAUPP were limited, corresponding to a 44% decrease in mean snoring intensity and 35% decrease in apnea-hypopnea index. Another randomized trial of LAUPP involved a randomized crossover design in which patients were randomly assigned to LAUPP or radiofrequency ablation (RFA) of the palate and then allowed to undergo the non-assigned treatment if their assigned treatment did not provide adequate improvement. Although this study was small (n=17) and involved only 16 weeks of follow-up, the results suggest that multiple LAUPP and RFA treatments of the palate reduce snoring but do not significantly reduce the other symptoms of sleep-disordered breathing such as daytime sleepiness or upper airway collapse. There has been little peer-reviewed study of laser-assisted uvulopalatopharyngoplasty (LAUPPP) for the treatment of OSA.

Tracheostomy, which simply bypasses the obstructing lesion of the upper airways, has been shown to be the most effective and predictable surgical approach to OSA. However, the social and medical morbidities of a permanent tracheostomy and the advent of surgical alternatives have made tracheostomy an unpopular solution to OSA, reserved for those patients with the most severe sleep apnea not manageable by other interventions.

The available evidence on hypoglossal nerve stimulation does not establish efficacy or reduce OSA severity, decrease incidence of clinical consequences, or reduce associated risk for occupational or motor vehicle accidents.


Reference

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2.    Chesson AL, Jr, Berry RB, Pack A. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. American Academy of Sleep Medicine. Sleep. 2003; 26(7):907-913.

3.    Agency for Healthcare Research and Quality (AHRQ), Technology Assessment Program. Effectiveness of portable monitoring devices for diagnosing obstructive sleep apnea: Update of a systematic review. Technology Assessment. Final Report. Prepared by RTI International for AHRQ. Rockville, MD: AHRQ: September 1, 2004.

4.    Hensley N, Ray C. Sleep apnoea. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2008.

5.    Kushida CA, Morgenthaler TI, Littner MR, et al.; American Academy of Sleep Medicine. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: An update for 2005. Sleep. 2006; 29(2):240-243.

6.    Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea. Health Care Guideline. 4th ed. Bloomington, MN: ISCI; March 2006.

7.    Ferguson K. Oral appliance therapy for obstructive sleep apnea: Finally evidence you can sink your teeth into. Am J Respir Crit Care Med. 2001; 163(6):1294-1295.

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13.   Vanderveken OM, Devolder A, Marklund M, et al. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med. 2008; 178(2):197-202.

14.   Ferguson KA, Cartwright R, Rogers R, et al. Oral appliances for snoring and obstructive sleep apnea: A review. Sleep. 2006; 29(2):244-262.

15.   Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: A randomized, controlled trial. Am J Respir Crit Care Med. 2002; 166(5):743-748.

16.   Henke K, Frantz DE, Kuna ST. An oral elastic mandibular advancement device for obstructive sleep apnea. Am J Respir Crit Care Med. 2000; 161:420-425.

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18.   Riley RW, Powell NB, Guilleminault C. Inferior mandibular osteotomy, and hyoid Myotomy suspension for obstructive sleep apnea. A review of 55 patients. J Oral Maxillofacial Surg. 1989; 47:159-164.

19.   Wright J, Johns R, Watt I, et al. Health effects of obstructive sleep apnea, and the effectiveness of continuous positive airways pressure: A systematic review of the research evidence. BMJ. 1997; 314(7084):851-860.

20.   Findley L, Smith C, Hooper J, et al. Treatment with nasal CPAP decreases automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med. 2000; 161(3 Pt 1):857-859.

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25.   Hoffstein V, Viner S, Mateika S, Conway J. Treatment of obstructive sleep apnea with nasal continuous airway pressure: Patient compliance, perception of benefits and side effects. Am Rev Respir Dis. 1992; 145(4 Pt 1):841-845.

26.   Krieger J. Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers. Sleep. 1992; 15(6):S42-S46.

27.   Pepin JL, Krieger J, Rodenstein D, et al. Effective compliance during the first 3 months of continuous positive airway pressure treatment. A European prospective study of 121 patients. Am J Respir Crit Care Med. 1999; 160(4):1124-1129.

28.   Riley, RW, Powell NB, Guilleminault C. Maxillary mandibular and hyoid advancement for treatment of obstructive sleep apnea. A review of 40 patients. J Oral Maxillofacial Surg. 1990; 48:20-26.

29.   Riley RW, Powell NB, Guilleminault C. Inferior mandibular osteotomy, and hyoid Myotomy suspension for obstructive sleep apnea. A review of 55 patients. J Oral Maxillofacial Surg. 1989; 47:159-164.

30.   Smith I, Nadig V, Lasserson TJ. Educational, supportive, and behavioral interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009 ;( 2): CD007736.

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33.   Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008; 31(8):1071-1078.

34.   Marshall NS et.al. Sleep Apnea as an Independent Risk Factor for All-Cause Mortality: The Busselton Health Study. Sleep. 2008; 31(8):1079-1085.

35.   Hayes News Service.  FDA approves implantable Neurostimulator to treat sleep apnea.  7 May 2014.

36.   Malhotra A.  Hypoglossal-nerve stimulation for obstructive sleep apnea.  NEJM. 2014;370(2):170-171

37.   Strollo PJ et al. Upper-airway stimulation for obstructive sleep apnea.  NEJM 2014; 370(2):139-149.

38.   Rosen Carol L, et al. A multisite randomized trial of portable sleep studies and positive airway autotitration versus laboratory-based polysomnography for the diagnosis and treatment of Obstructive Sleep Apnea: The Home PAP Study. Sleep.  2012: 35(6): 757-767.

39.   Berry, Richard B, et al. "Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea." Sleep. 2008; 31(10): 1423-1431.

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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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