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Polysomnogram (PSG) (Custom) - UDOH

Polysomnogram (PSG) (Custom) - UDOH

2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH(1, 2*MDR, 3, 4, 5, 6) Created based on InterQual Subset: Polysomnogram (PSG) Version: InterQual® 2009

CLIENT: Name D.O.B. ID# GROUP# CPT/ICD9: Code Facility Service Date PROVIDER: Name ID# Phone# Signature Date

ICD-9-CM: 89.17

INDICATIONS (choose one and see below)

100 Suspected 200 Follow-up study after Rx 300 Repeat study in untreated sleep apnea patient 400 Suspected 500 Suspected idiopathic 600 Suspected periodic limb 700 Suspected Indication Not Listed (Provide clinical justification below)

(7, 8, 9) 100 Suspected sleep apnea [One] 110 Sx/findings during sleep [Two] (10) 111 112 Gasping/choking (11) 113 Irregular pattern 120 Witnessed sleep pattern consistent with sleep apnea and Sx/findings while awake [One] 121 (12) 122 Hypersomnolence (13) 123 Irritability/moodiness (14) 124 Morning headaches 130 Unexplained hypersomnolence [All] (12) 131 Hypersomnolence [One] -1 Impairment of job performance (15) -2 Impairment of safety -3 Hypersomnolence > 8 wks (16) 132 Symptoms interfere with ADLs 133 excluded by Hx InterQual® criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determination concerning the type or level of medical care provided, or proposed to be provided, to the patient. The Clinical Content is confidential and proprietary information and is being provided to you solely as it pertains to the information requested. Under copyright law, the Clinical Content may not be copied, distributed or otherwise reproduced except as permitted by and subject to license with McKesson Corporation and/or one of its subsidiaries. InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 1 of 7 Licensed for use exclusively by Utah Department of Health. 2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

(17) 200 Follow-up study after sleep apnea Rx [One] (18) 210 CPAP/BiPAP [One] (19) 211 Titration of CPAP/BiPAP settings 212 Sx/findings after Rx [Both] -1 Persistent/worsening/recurrent symptoms (20) -2 Adherence to prescribed Rx (21, 22, 23) 220 UPPP/dental appliance [One] (24) 221 Follow-up assessment (25) 222 Persistent/worsening/recurrent symptoms after Rx

(26) 300 Repeat study in untreated sleep apnea patient [Both] (12, 27) 310 Sleep apnea symptoms [One] (28) 311 New/worsening symptoms 312 Symptoms interfere with ADLs (29) 320 Treatment planned

(30) 400 Suspected narcolepsy [All] (12, 31) 410 Hypersomnolence > 8 wks 420 Findings [One] 421 Disrupted nocturnal sleep (32, 33) 422 (34) 423 Hypnagogic/ hallucinations (35) 424 (36) 430 Medical/psychiatric conditions excluded

(37) 500 Suspected [All] (12, 31) 510 Hypersomnolence > 8 wks 520 Findings [One] 521 Difficult morning awakening 522 Constant 523 Prolonged night sleep 524 Sleep drunkenness (38) 525 Sleep-related behaviors disruptive to other household members 526 Frequent/prolonged daily (36) 530 Medical/psychiatric conditions excluded

(39) 600 Suspected periodic limb movement disorder [All] (12) 610 Hypersomnolence/insomnia > 8 wks

InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 2 of 7 Licensed for use exclusively by Utah Department of Health. 2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

(16) 620 Symptoms interfere with ADLs (40) 630 Witnessed periodic body/limb movements

(41) 700 Suspected parasomnia [All] (12) 710 Hypersomnolence > 8 wks (16) 720 Symptoms interfere with ADLs 730 Insomnia excluded by Hx (42) 740 Sleep-related behaviors/findings [One] (38) 741 Disruptive to other household members 742 Potentially violent/injurious 743 Sleep-related excluded by EEG

Notes

(1) These criteria include the following procedure: (2)-MDR: Utah Medicaid will reimburse for 1-PSG 95810 and 1-PSG 95811 per year without prior authorization. Requests that exceed the limit of (1) per code per year and meet UDOH Custom Criteria will require secondary medical review by the Utilization Review Committee before prior authorization is given. (3) Polysomnogram (PSG) is a sleep study used to diagnose specific sleep disorders, primarily (OSA). The parameters typically monitored include brain wave activity, eye movements, REM sleep, limb movement, heart rate and rhythm, airflow through the nose and mouth, chest wall excursion, oxygen saturation, snoring loudness, and sleep position. (4) A standard PSG study gathers diagnostic data and titrates CPAP in a laboratory setting over a 2-night period. A split-night sleep study is a variation of the standard PSG in which the diagnostic PSG and CPAP titration are completed in one night. A split-night study is likely to be more accurate for patients with a high pretest probability for OSA (Patel et al., Chest 2007; 132(5): 1664-1671; Kushida et al., Sleep 2005; 28(4): 499-521). (5) In addition to a facility-based PSG, portable monitoring devices are also being used in the home to diagnose OSA. Although results may be less accurate, a home study may be acceptable based on the patient's clinical presentation and the medical practitioner's judgment. A home study may be appropriate for patients with a high pretest probability of OSA or for patients that are unable to have the study performed in the sleep laboratory (e.g., severe , nonambulatory). The home study may also be used to monitor a patient's response to non-CPAP treatments, such as oral appliances or upper airway surgery (Ahmed et al., Chest 2007; 132(5): 1672- 1677; Collop et al., J Clin Sleep Med 2007; 3(7): 737-747; Kushida et al., Sleep 2005; 28(4): 499-521). (6)-POL: Utah Medicaid will reimburse for 1-PSG 95810 and 1-PSG 95811 per year without prior authorization. All requests that exceed the limit of (1) per code per year will require prior authorization using the UDOH Custom Criteria and will require secondary medical review by the Utilization Review Committee before approval is given. (7) Sleep apnea is a condition in which a patient's breathing nearly or completely stops for periods of 10 seconds or more during sleep. It is estimated to affect 2% to 4% of adults 30 to 60 years of age (Norman and Loredo, Clin Geriatr Med 2008; 24(1): 151-165, ix; Patil et al., Chest 2007; 132(1): 325-337). There are several types of sleep apnea: • Obstructive (upper respiratory airflow blockage during sleep)

InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 3 of 7 Licensed for use exclusively by Utah Department of Health. 2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

• (decreased depth and rate of respiration during sleep) • Central (no respiratory effort made during sleep in the absence of obstruction) • Mixed (any combination of the above) • Complex (central apnea associated with CO regulation and obstructive airway disease) 2 Obstructive sleep apnea (OSA) may be treated with , surgery (e.g., UPPP), or with the use of oral or dental appliances. Untreated OSA has been associated with an increase in the risk of or death from any cause (Ahmed et al., Chest 2007; 132(5): 1672-1677). Central apnea is generally treated with (e.g., acetazolamide, TCAs) or with positive airway pressure. (8) These criteria are based primarily on symptoms reported by the patient or their significant other. Certain upper airway abnormalities such as tonsillar hypertrophy, an enlarged soft palate, a narrow oropharynx, nasal polyps, septal deviation, retrognathia, or an increased neck size found on PE support the diagnosis of sleep apnea. (9) Hypothyroidism and OSA share similar symptoms and there may be an etiologic relationship between the two conditions. The benefit of treating hypothyroidism remains unclear but symptoms may resolve in selected cases when hypothyroidism is treated (Norman and Loredo, Clin Geriatr Med 2008; 24(1): 151-165, ix). (10) Although habitual snoring is a classic finding in OSA, it is not universal. Furthermore, patients who snore may not have witnesses to report their snoring. Therefore, snoring is not a required criterion but will be present in the majority of patients. (11) Cheyne-Stokes respiration with central apnea is an irregular breathing pattern commonly seen in patients with moderate to severe CHF. Patients have apneic episodes followed by periods of hyperventilation that continually cycle during sleep. (12) Hypersomnolence (i.e., excessive daytime sleepiness) can sometimes be very subtle. Patients may complain of the inability to function at optimum levels during the day, have difficulty concentrating, or may perform poorly at work. Some patients doze off at any given opportunity. (13) Personality changes such as new moodiness or irritability may be a consequence of persistent or chronic fragmented sleep. Other more common causes of sleep disturbance (e.g., side effects, psychological , , other medical or psychological illnesses) should be excluded through a thorough medical history and PE. (14) Morning headaches which typically resolve within 1 to 2 hours of awakening are suggestive of sleep apnea, although other etiologies of morning headache should always be considered, including intracranial masses and increased ICP. The morning headaches from sleep apnea result from prolonged periods of and . (15) Hypersomnolence may impair the safety of those who drive or operate machinery; these individuals are a potential threat to themselves and others. (16) Activities of daily living (ADLs) are frequently divided into those simple activities relating to basic self-care and those that involve more complex interactions with others and the environment (called instrumental activities of daily living or IADLs). This criterion includes both types of activity. Whether a condition is of sufficient severity to interfere with ADLs or IADLs is somewhat subjective. There should be an indication that symptoms impede the patient's ability to effectively work, shop, manage at home, care for family members, or tend to personal hygiene. (17) PSG is used to evaluate the efficacy of a therapeutic intervention. The timing of this follow-up PSG is a matter of clinical judgment. (18) CPAP and BiPAP are both effective means of treating OSA. Positive pressure serves to splint the pharyngeal airway and prevent occlusion which can cause the apneic episodes. BiPAP may be better tolerated because it allows for easier expiration against positive

InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 4 of 7 Licensed for use exclusively by Utah Department of Health. 2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

pressure (Chowdhuri, Otolaryngol Clin North Am 2007; 40(4): 807-827). (19) PSG should be performed on patients treated with CPAP or BiPAP to monitor the therapeutic effects when a change in pressure is made. Patients who gain or lose significant weight (i.e., 10% body weight) may require a change in their CPAP settings in order to maintain a patent airway during sleep (Kushida et al., Sleep 2005; 28(4): 499-521). (20) Adherence refers to continued patient use of the equipment as prescribed by the physician. Patient noncompliance with noninvasive positive pressure therapy is very high but may be improved by patient education, proper fitting of the face or nasal mask, physician follow-up, and by attending support group meetings. Objective data regarding patient adherence may be obtained by downloading the device's internal records or by monitoring the hour meter recorder (Chowdhuri, Otolaryngol Clin North Am 2007; 40(4): 807-827). (21)-DEF: UPPP is the excision of the uvula and partial excision of soft tissue of the palate and lateral pharyngeal walls. (22) UPPP is a surgical procedure aimed at reducing obstruction and thereby enlarging the airway in an attempt to alleviate OSA. There are several other surgical procedures, such as laser-assisted uvulopalatoplasty (LAUP), that have not been proven to be effective for mild to moderate symptoms of sleep apnea (Sundaram et al., Cochrane Database Syst Rev 2005; (4): CD001004). (23) There are two types of dental appliances used to treat OSA; a tongue retaining device (TRD) holds the tongue forward to keep the airway open while a mandibular advancement device (MAD) uses the teeth and device positioning to pull the mandible forward to keep the airway open. (24) A repeat study is indicated for patients with moderate to severe obstructive sleep apnea to ensure the effectiveness of treatment (e.g., surgery, oral appliances) (Kushida et al., Sleep 2005; 28(4): 499-521). (25) Symptoms may recur after an initial positive response to surgery or an oral appliance; repeat PSG should be performed to determine if additional measures need to be instituted (Kushida et al., Sleep 2005; 28(4): 499-521). (26) Patients who choose not to adhere to therapy for their sleep apnea may do so because they find it cumbersome and uncomfortable. Surgery may be rejected as an option to correct the problem or they may not be surgical candidates because of comorbid medical conditions (Guilleminault and Abad, Med Clin North Am 2004; 88(3): 611-630, viii). (27) Often it is the patient's significant other who first recognizes an abnormal sleep pattern. They may witness persistent or rhythmic gasping, choking, or irregular breathing. Although most patients with OSA habitually snore, those with sleep disruption and daytime symptoms should receive further evaluation, even in the absence of a snoring history. (28) Obesity is frequently associated with OSA. individuals who gain additional weight may be at increased risk for symptomatic OSA (Stierer and Punjabi, Anesthesiol Clin North America 2005; 23(3): 405-420, v). CHF is another risk factor associated with sleep apnea. Cardiac output may improve when patients with CHF and central or OSA have CPAP added to their existing medical regime (Kushida et al., Sleep 2005; 28(4): 499-521; Ting and Malhotra, Prim Care 2005; 32(2): 305-318, v). (29) Repeat PSG is warranted only when test results will impact patient treatment. (30) Narcolepsy is a condition characterized by an abnormal tendency to fall asleep during normal periods of wakefulness. The quality of the sleep is poor in narcolepsy. The main characteristics include excessive daytime sleepiness, cataplexy, sleep paralysis, and hallucinations. Nonpharmacological treatment of narcolepsy consists of adhering to a schedule of regular sleep times and mid-day naps. Pharmacological therapy include psychostimulants and (Morgenthaler et al., Sleep 2007; 30(12): 1705-1711; Young and Silber, Chest 2006; 130(3): 913-920). have been prescribed for cataplexy, although there is no evidence their use improves symptoms (Vignatelli et al., Cochrane Database Syst Rev 2008; (1): CD003724).

InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 5 of 7 Licensed for use exclusively by Utah Department of Health. 2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

(31) Hypersomnolence may be exacerbated by disturbed nocturnal sleep. (32)-DEF: Cataplexy is defined as a sudden loss of muscle tone without a loss of consciousness and is generally triggered by an emotional event such as laughter, surprise, fear, or anger. (33) Cataplexy can be seen in more than 60% of patients diagnosed with narcolepsy. The attacks can be mild (as exhibited by head drooping or slurred speech) or severe (with complete atonia leading to paralysis and collapse while the patient is awake and alert) (Black et al., Neurol Clin 2005; 23(4): 1025-1044). (34)-DEF: Hypnagogic hallucinations are vivid dreamlike states which occur during the transition from wakefulness to sleep; hypnopompic hallucinations occur when waking up. (35)-DEF: Sleep paralysis is the transient inability to move upon awakening. (36) Patients should be evaluated to ensure that the excessive daytime sleepiness is not related to other more common causes such as insufficient sleep, mononucleosis, medication, or psychiatric conditions (e.g., ). These conditions should be excluded prior to PSG. (37) Idiopathic hypersomnia, also known as idiopathic central nervous system hypersomnia, is a syndrome thought to be caused by the inability of internal mechanisms to control non-REM sleep. It typically begins in adolescence or young adulthood and persists throughout life. Idiopathic hypersomnia is associated with a normal or prolonged undisturbed major sleep episode, lasting up to 20 hours, which significantly impairs patient performance. Patients complain of constant somnolence during the day and night, the need to take lengthy naps, prolonged night sleep, major difficulty with morning awakening, and sleep drunkenness. There are no REM sleep abnormalities or cataplexy as with narcolepsy, and naps may or may not help in reducing sleepiness. The primary treatment of idiopathic hypersomnia consists of medication management with stimulants (Anderson et al., Sleep 2007; 30(10): 1274-1281; Morgenthaler et al., Sleep 2007; 30(12): 1705-1711). (38) Patients with this condition have difficulty waking up in the morning. They may become physically or verbally abusive or irritable to household members attempting to wake them. (39) Periodic limb movement disorder is characterized by repetitive movement of the lower extremities and sometimes the upper limbs during sleep. Patients complain of insomnia, frequent awakenings, nonrefreshing sleep, excessive daytime sleepiness, and have no other sleep-related medical or psychiatric disorders to account for their symptoms. partner observation assists in the establishment of the diagnosis. Unlike restless leg syndrome, which is diagnosed by patient history, the diagnosis of periodic limb movement disorder is based on polysomnogram confirmation (Kushida et al., Sleep 2005; 28(4): 499-521; Rama and Kushida, Med Clin North Am 2004; 88(3): 653-667, viii). (40) The diagnosis of periodic limb movement disorder can be confirmed by PSG which documents the frequency of the arousals secondary to limb movement. PSG also provides details on other sleep disorders when present (Kushida et al., Sleep 2005; 28(4): 499-521). (41) Parasomnia is a with physical and behavioral attributes which are manifested as the brain transitions between the stages of sleep or wakefulness. Classified as primary or secondary, can occur during any stage of sleep, in children as well as adults. Common primary parasomnias seen during the non-REM stages of sleep are known as disorders of arousal and are exemplified by or sleep terrors. The parasomnia which occurs during REM sleep is called REM sleep behavior disorder and is caused by the loss of normal atonia during REM sleep. Patients may act out their by yelling, swearing, jumping, or running. Since there is a strong association between this type of parasomnia and several CNS conditions, patients exhibiting these behaviors should be evaluated neurologically. Secondary parasomnias occur when existing medical conditions are manifested during sleep (e.g., ,

InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 6 of 7 Licensed for use exclusively by Utah Department of Health. 2009 Procedures Adult Criteria Polysomnogram (PSG) (Custom) - UDOH

headaches, chest pain, panic attacks) (Lee-Chiong, Prim Care 2005; 32(2): 415-434; Mahowald and Schenck, Neurol Clin 2005; 23(4): 1077-1106, vii). (42) Parasomnias may be associated with medical or psychiatric symptoms or findings. In these circumstances, when there is risk of or harm to self or others or the household routine is disturbed, studies using PSG with expanded EEG monitoring and audiovisual recording can assist in defining the scope of the condition. Parasomnias can be treated in most situations (Mahowald and Schenck, Neurol Clin 2005; 23(4): 1077-1106, vii).

InterQual® copyright © 2009 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications. May contain CPT® codes. CPT only © 2008 American Medical Association. All Rights Reserved. Page 7 of 7 Licensed for use exclusively by Utah Department of Health.

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