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AIM's clinical guidelines for sleep services include information on:
- CPT and HCPCS Codes addressed by the policy
- Sleep testing guidelines for home and in-lab tests
- APAP and CPAP guidelines
- Bi PAP guidelines
- Oral appliances for OSA guidelines (page 20-22)
In the oral appliances for OSA section, the guidelines for patients diagnosed with severe OSA state:
"Treatment with OA is appropriate for patients with severe OSA (apnea/hypopnea index [AHI] greater than 30) meeting at least one of the criteria (1-3) below:
1. The patient is not a candidate for positive airway pressure therapy; or
2. Positive airway pressure therapy has not been effective despite a 45 day trial and participation in a positive airway pressure compliance program; or
3. The patient has tried continuous positive airway pressure (CPAP) but has not been compliant despite a 45 day trial and participation in a positive airway pressure compliance program."
For patient's diagnosed with mild to moderate OSA, the guidelines state:
"Treatment with OA is appropriate for patients with mild or moderate OSA meeting both of the following criteria (A and B) below:
A. At least one of the following:
1. AHI greater than or equal to 15 and less than or equal to 30; or
2. AHI 5–14 with any of the following: excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, treatment-resistant hypertension (persistent hypertension in a patient taking three or more anti-hypertensive medications), ischemic heart disease, history of stroke;
AND
B. At least one of the following:
1. The patient is not a candidate for positive airway pressure therapy; or
2. Positive airway pressure therapy has not been effective despite a 45 day trial and participation in a positive airway pressure compliance program; or
3. The patient has tried CPAP but has not been compliant despite a 45 day trial and participation in a positive airway pressure compliance program; or
4. The patient prefers to use an OA rather than PAP as the initial therapy"
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