A continuous positive airway pressure (CPAP) device is considered medically necessary DME when used in the treatment of otherwise healthy children older than 1 year with obstructive sleep apnea syndrome (OSAS) secondary to adenotonsillar hypertrophy and/or obesity and who are not in cardiorespiratory failure when the apnea index is greater than 1 on nocturnal polysomnography (NPSG) and when any of the following is met:

• Adenotonsillectomy is contraindicated; or
• There is minimal adenotonsillar tissue; or
• There is persistent OSAS after Adenotonsillectomy.

When the above criteria are met, payment will be made for the rental of a CPAP device for the first three months from the original start date of therapy. After children have been using a CPAP device for three months, are found to be maintaining compliance with its use, and are experiencing success in treatment, payment will be made for the purchase of the device (after the expenses incurred for the first three month’s rental have been applied to the purchase price). Compliance is defined as CPAP use of >4 hours per night of use and ≥5 nights per week, supported by meter readings via built-in monitoring chip.

NOTE:

A child is defined as one (1) through seventeen (17) years of age.

Services that do not meet the medical necessity guidelines on this policy will be considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

NOTE:

See Medical Policy Bulletin Z-64 for further information on the diagnosis and treatment of obstructive sleep apnea in children.

NOTE:

See Medical Policy Bulletin E-20 for further information on continuous positive airway pressure (CPAP) devices.

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

A continuous positive airway pressure (CPAP) device is an electronic device that delivers constant air pressure via a nasal mask, leading to mechanical stenting of the airway and improved functional residual capacity in the lungs. The pressure requirement varies among individuals, so CPAP must be titrated in the sleep laboratory before prescribing the device and periodically readjusted thereafter. 

OSAS in children is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.

The presentation of obstructive sleep apnea in children may differ from that of adults. Children frequently exhibit behavioral problems or hyperactivity rather than daytime sleepiness. Daytime sleepiness may occur, but is uncommon in young children. Symptoms in children may include habitual (nightly) snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems. An apnea/hypopnea index (AHI) >1 is considered abnormal (an AHI of 15 is considered severe).

OSA can occur in children of all ages, from neonates to adolescents. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders. In otherwise healthy children, OSA is usually associated with adenotonsillar hypertrophy and/or obesity.

The first- line treatment for pediatric OSAS is usually adenotonsillectomy. Continuous positive airway pressure (CPAP) is an option for children who are not candidates for surgery or who have an inadequate response to surgery. Patients should be reevaluated post-operatively to determine whether additional treatment is required.

CPAP is a long-term therapy and requires frequent clinician assessment of adherence and efficacy.

Left untreated, OSAS can result in complications, which may include neurocognitive impairment, behavioral problems, failure to thrive, and cor pulmonale, particularly in severe cases.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

National Blue Cross Blue Shield Association Medical Policy 2.01.18, Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome, 01/2010

Michael S. Schechter, MD, MPH and Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical Report: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2002;109(4):e69-e69.

American Academy of Pediatrics (AAP). Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2002;109(4):704-712.

Millman RP. Working Group on Sleepiness in Adolescents/Young Adults; AAP Committee on Adolescence. Excessive Sleepiness in Adolescents and Young Adults: Causes, Consequences, and Treatment Strategies. Pediatrics. 2005 Jun;115(6):1774-86.

Uong EC, Epperson M, Bathon SA, Jeffe DB. Adherence to Nasal Positive Airway Pressure Therapy Among School-aged Children and Adolescents with Obstructive Sleep Apnea Syndrome. Pediatrics. November 2007;120(5):e1203-e1211.

Marcus CL. OSA in Children. American Sleep Apnea Association website -  http://www.sleepapnea.org/resources/pubs/children-osa.html. Accessed May 24, 2010.

Benninger M, Walner D. Obstructive Sleep-Disordered Breathing in Children. Clinical Cornerstone.  2007;9(1):S6-S12.

Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D. Pediatric Obstructive Sleep Apnea: Complications, Management, and Long-term Outcomes. Proc Am Thorac Soc. 2008 Feb 15;5(2):274-82.
 
Tsara V, Amfilochiou A, Papagrigorakis J M, et al. Guidelines for Diagnosing and Treating Sleep Related Breathing Disorders in Adults and Children (Part 3: Obstructive Sleep Apnea in Children, Diagnosis and Treatment). Hippokratia. 2010 Jan-Mar;14(1):57-62.