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MP 2.01.18 Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

Medical Policy    
Subsection Last Review Status/Date
Updated by AIM 1/2014-  last reviewed/10:2014
Original Policy Date
Return to Medical Policy Index


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 

Related Policies

1.01.06 Home Apnea Monitoring
2.01.73 Actigraphy
7.01.101 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome


Blue Cross of Idaho follows AIM Specialty Health Sleep Disorder Management Diagnostic and Treatment Guidelines.

These guidelines can be accessed at:[]

All sleep studies must be read and interpreted by a physician board-certified in sleep medicine in order to be considered valid.

Regarding Oral Appliances, these are only considered medically necessary when the AIM criteria for this therapy are met AND the referral for an oral appliance comes from a physician.

Regarding Medicare Advantage Patients:

Blue Cross of Idaho Medicare Advantage plans follow the medical policies of the Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) for the Medicare contractors in the state of Idaho.

Policy History

Date Action Reason
11/96 Add policy New policy
10/08/02 Replace policy Policy updated; specific patient selection criteria for CPAP, BiPAP added
02/25/04 Replace policy Policy updated; additional discussion of portable sleep studies; policy statement unchanged
04/1/05 Replace policy Policy updated with focus on APAP; reference numbers 4–8 added. Policy statement revised by including APAP as an alternative after a failed trial of CPAP
12/14/05 Replace policy – coding update only HCPCS codes updated
07/20/06 Replace policy Policy updated. Atrial pacing added as an investigational treatment. No other changes to policy statements. Reference numbers 13–16 added. HCPCS coding updated in policy guidelines and coding table.
01/10/08 Replace policy Policy updated with literature review, references 1, and 18–23 added (reference list renumbered); no change in policy statements.
05/30/08 Update policy -coding upate only  Added new HCPCS codes for 2008 
3/30/09 replace policy- local  changed indication for oral appliance to indicate only covered for 'mild to moderate' OSA 
06/11/09 Replace local policy - coding update only New CPT category III codes effective 1/1/10 added to policy
02/25/10 replace policy - local changed AHI for oral appliance to ≤ 40
4/14/11 replace policy- local status removed Policy updated with literature review through January 2011; references 3, 4 and 12 added; criteria added for oral appliances; other policy statements unchanged
01/13/12 replace policy- LOCAL policy retained statement regarding oral appliance AHI <40
4/12/12 replace policy - remains local Policy updated with literature review through February 2012; references 7, 32, 33, 38 and 39 added; criteria for oral appliances clarified; nasal expiratory positive airway pressure (EPAP) added as investigational
6/13/13 Replace policy- no longer local Policy updated with literature review through April 16, 2013; references 30,31,40 added and reordered; oral pressure therapy added as investigational; clarification of a single night for a home sleep study; clarification of adult patients in the statement on oral appliances; PAP-NAP studies considered investigational; telemonitored home sleep studies addressed in Policy Guidelines and Benefit Application section
6/12/14 Replace policy Policy updated with literature review through May 29, 2014; references 33-34 and 55 added; policy statements unchanged
10/31/14 replace local policy policy updated to reflect AIM Specialty Health as the vendor and resource for med nec review


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