<img height="1" width="1" style="display:none" src="https://www.facebook.com/tr?id=1717549828521399&amp;ev=PageView&amp;noscript=1">

«  View All Posts

Blog Feature

By: Laura Linley, CRT, RPSGT, FAAST on February 22nd, 2019

Print/Save as PDF

Compliance Corner


On Aug. 8, 2018, Carecentrix released its criteria for determining the medical necessity for the diagnosis and treatment of sleep disordered breathing in adults and children. I wanted to take this opportunity to review their guideline for home sleep apnea testing (HSAT).

Carecentrix works with payors with coordination of care for sleep-disordered patients from diagnosis through sleep therapy management.

In my business managing labs in Texas, HSAT is the fastest growing service, and I am often asked to review the rationale behind the decisions made in determining which test to use. I probably should preface this with the statement that Carecentrix publishes this as a guideline only. The guideline does not represent medical advice. Medical decisions are the responsibility of the patient and the attending physician. Benefits are determined by the health plan and employer group contract and eligibility of the subscriber at the time services are rendered.

An HSAT (95800, 95801, 95806, G0398, G0399, G0400) is an unattended sleep study administered using a portable monitoring device that measures physiologic indicators of respiratory activity during sleep, unattended, in a setting outside of the sleep center facility for adult patients, age 18 years or older. HSAT is the preferred method to diagnose obstructive sleep apnea (OSA) when OSA is suspected and there are no comorbid conditions which may necessitate attended monitoring or that could degrade the accuracy of HSAT.

An initial HSAT may be medically necessary when all of the following conditions are met:

  1. Signs and symptoms of sleep-disordered breathing are present
  2. Absence of other comorbid medical conditions or concomitant sleep disorders that could degrade the accuracy of HSAT
    • Comorbid medical conditions which would degrade HSAT include:
      • Moderate to severe COPD or asthma, as diagnosed on pulmonary function studies (PFTs)
      • Moderate to severe congestive heart failure (NYHA Class III or IV) or LVEF less than or equal to 45 percent
      • Moderate to severe pulmonary hypertension, with pulmonary artery pressure greater than 40 mm Hg or neuromuscular/neurodegenerative disorder causing restrictive lung disease, such as: severe kyphoscoliosis, myasthenia gravis, amyotrophic lateral sclerosis (ALS), post-polio syndrome, polymyositis, and Guillain-Barre syndrome
      • Acute, uncontrolled cardiac arrhythmia(s) supported by clinical documentation
      • Chronic opioid medication use
    • Secondary concomitant or associated sleep disorders which would degrade HSAT include:
      • Previously diagnosed periodic limb movement disorder (PLMD), defined as greater than or equal to 15 periodic limb movements per hour resulting in arousal when the arousals are not associated with respiratory events
      • Complex parasomnias, with potentially injurious, disruptive or violent behavior, such as REM Behavior Disorder (RBD) or sleep walking
      • Narcolepsy, or narcolepsy-related symptoms, after OSA has been evaluated and effectively treated as documented by the patient’s objective adherence to therapy (PAP download)
      • Obesity hypoventilation syndrome (OHS), defined as pCO2 greater than 45 mm Hg and pO2 less than 60 mm Hg on arterial blood gas
      • Central sleep apnea (CSA) or treatment-emergent sleep apnea, defined as central apneas and/or hypopneas greater than 50 percent of the total number of apneas and/or hypopneas and central apneas and/or hypopneas greater than or equal to five times per hour of sleep
      • Nocturnal seizures which are acute and/or not effectively controlled and occurring concomitantly with other sleep disorders.
  3. Cognitive and physical ability to safely and effectively perform the sleep test outside of the sleep laboratory
  4. Age 18 years or older

Understanding medical coverage policies is critical in getting proper sleep testing reimbursed, and, from a compliance perspective, everyone in your organization should understand the importance of gathering proper documentation to support testing and treatment. The review should start with making sure the referring physician has properly listed the necessity for testing; if the diagnosis of sleep disordered breathing is suspected, than those signs and symptoms must be documented in the office visit notes.

Signs and Symptoms of Sleep Disordered Breathing:

Initial testing for the diagnosis of sleep disordered breathing is appropriate via laboratory polysomnography (PSG) or home sleep apnea testing (HSAT) if a patient presents with at least one sign/symptom from category A and one sign/symptom from category B.

A.  Evidence of Excessive Daytime Sleepiness (EDS)

  • Disturbed or restless sleep
  • Non-restorative sleep
  • Frequent unexplained arousals from sleep
  • Fragmented sleep
  • Epworth Sleepiness Scale (ESS) greater than or equal to 10

B. Evidence Suggestive of Sleep Disordered Breathing (SDB)

  • Habitual snoring
  • Witnessed apneas during sleep
  • Choking or gasping during sleep
  • BMI greater than or equal to 30
  • Neck circumference greater than 17 inches (men) or greater than 16 inches (women).

This is an ongoing discussion in our organization, and we often review and ask others to review documentation to make sure as an organization that we are consistent in the understanding and implementation of the referral process. We use these guidelines as a communication point when visiting our referring provider offices.

AAST offers some management tools to support a sleep center’s HSAT program, including a Policy and Procedure Manual - HSAT Program guide.

To access the full Carecentrix guideline, please visit http://help.carecentrix.com/ProviderResources/SMS_PEIA_CRITERIA.pdf