Obstructive Sleep Apnea

According to Medicare guidelines, revised in 2002, CPAP is indicated for patients with an apnea-hypopnea index (AHI) > 15 events/hour (moderate severity), regardless of symptoms; and for patients with an AHI > 5 and < 14 (mild severity) with excessive daytime somnolence, impaired cognition, mood disorders, insomnia; or with the comorbidities of hypertension, ischemic heart disease, or stroke (47). However, the Medicare list of acceptable ICD-9 (International Classification of Diseases, ninth revision) codes that support medical necessity which justify the use of polysomnography to screen for and/or diagnose sleep-related breathing disorders includes only diagnoses of sleep disturbances or of hypersomnolence, disregarding comorbidities (48).

It is important to note, however, that in the seminal Wisconsin Cohort Study, it was found that only 15.5% of males and 22.6% of females with documented obstructive sleep-related respiratory events (i.e., AHI), at a rate of five events per hour or more, reported sleepiness on all three subjective measures assessed (49). Additionally, the Wisconsin Cohort Study showed a dose-response association between sleep-disordered breathing at baseline and the presence of hypertension four years later that was independent of other known risk factors, even in the presence of only mild OSA [odds ratio (OR) = 2.03; 1.2-3.17].

Based upon these data, it is prudent to screen patients with diagnostic poly-somnography at risk for or previously diagnosed with primary hypertension in the presence of other associated risk factors that increase the suspicion of OSA, including witnessed apneas, snoring, obesity, large neck circumference, and a small posterior airway space, with or without overt sleep complaints. If OSA is detected, even of mild severity, then treatment with PAP therapy is warranted. Accordingly, current

Medicare guidelines support the treatment of patients with mild OSA and cardiovascular comorbidities. However, based upon current Medicare guidelines, the current indication for diagnostic polysomnography precludes the routine screening of these patients without overt sleep complaints.

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