D9956 — Admin home sleep apnea test
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- NPSG performed in a healthcare facility and attended by a technologist; documentation of the NPSG report and interpretation by a qualified physician.
- For diagnosis: objective NPSG results (including AHI/apnea index, RDI, oxygen desaturation values) to support diagnosis of OSAS or to differentiate from primary snoring.
- For post-operative NPSG: documentation of timing (study should be delayed 6 to 8 weeks post-operatively) and indication for repeat study (age <3 years; cardiac complications; craniofacial anomalies; failure to thrive; neuromuscular disorders; obesity; prematurity; recent respiratory infection; severe pre-op OSAS with RDI ≥ 19; persistent symptoms).
- For hypoglossal nerve stimulation (HNS): documentation that member is between ages 13 to 18 years; AHI > 10 and < 50; evidence that member does not have complete concentric collapse at the soft palate level (e.g., DISE findings); documentation that adenotonsillectomy is contraindicated or was not effective; documentation of confirmed failure of, or inability to tolerate, PAP therapy despite attempts to improve compliance; and documentation that standard of care alternatives/adjunct therapies were considered.
Key Coverage Criteria
- Nocturnal polysomnography (NPSG) for children and adolescents younger than 18 years of age when performed in a healthcare facility for any of the following indications: To diagnose obstructive sleep apnea syndrome (OSAS) and differentiate it from snoring; or To evaluate hypersomnia; or Suspected narcolepsy (with MSLT); or Suspected parasomnia; or Suspected restless leg syndrome; or Suspected periodic limb movement disorder; or Suspected congenital central alveolar hypoventilation syndrome; or Su [...]
- NPSG for children when performed in a healthcare facility after an adenotonsillectomy or other pharyngeal surgery for OSAS when any of the following is met (study should be delayed 6 to 8 weeks post-operatively): Age younger than 3 years; or Cardiac complications of OSAS (e.g., right ventricular hypertrophy); or Craniofacial anomalies that obstruct the upper airway; or Failure to thrive; or Neuromuscular disorders (e.g., Down syndrome, Prader-Willi syndrome and myelomeningocele); or Obesity; or [...]
- Adenoidectomy and/or tonsillectomy for treatment of OSAS in children with habitual snoring when the apnea index is greater than 1 on a NPSG;
- Continuous positive airway pressure (CPAP) for treatment of OSAS in children when any of the following is met: Adenoidectomy or tonsillectomy is contraindicated; or Adenoidectomy or tonsillectomy is delayed; or Adenoidectomy or tonsillectomy is unsuccessful in relieving symptoms of OSAS.
- Aetna considers CPAP medically necessary for treatment of tracheomalacia.
- Lingual tonsillectomy (e.g., endoscopic-assisted coblation lingual tonsillectomy) and/or tongue base reduction to treat tongue base collapse in children with persistent OSA after adenotonsillectomy (e.g., in children with obesity, Down syndrome, and craniofacial or neuromuscular disorders);
1 Active Policy
AETNA-CPB-0752 — Obstructive Sleep Apnea in Children
Related Codes
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