CIGNA Medical, Philadelphia, has released its Medical Coverage Policy for Obstructive Sleep Apnea Diagnosis and Treatment Services, effective October 15, 2008. The coverage policy applies to all plans administered by CIGNA companies including plans administered by Great-West Healthcare, which is now a part of CIGNA.
CIGNA’s policy covers adult and pediatric in-laboratory polysomnography as medically necessary. Additionally, the CIGNA policy includes coverage of home sleep testing for the diagnosis of OSA when medically necessary for adults, but excludes coverage for children.
According to the coverage policy, CIGNA covers a home/portable sleep study as medically necessary as an alternative to PSG for the diagnosis of OSA in an adult when ALL of the following criteria are met:
• Type II or Type III device is used, with the ability to record, at a minimum, ventilation (at least two channels of respiratory movement, or respiratory movement and airflow); electrocardiography or heart rate; and oxygen saturation
• Individual meets ANY of the following criteria:
o High pretest probability of OSA (eg, loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep)
o OSA is suspected and in-laboratory PSG is not possible
o Diagnosis of OSA has been established, therapy has been initiated, and response to treatment is to be evaluated
• No significant co-morbid conditions that could impact the accuracy of the study (eg, moderate to severe pulmonary disease, neuromuscular disease, congestive heart failure)
• No sleep disorders other than OSA are suspected (eg, central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders, narcolepsy)
The policy also explicitly lists certain devices/procedures that the insurance company will not cover. According to the policy, “CIGNA does not cover the following devices/procedures for the diagnosis of OSA or other sleep disorders because they are considered experimental, investigational or unproven (This list may not be all-inclusive):
The full policy can be downloaded here.