![]() PSG demonstrates EITHER of the following:.PSG reveals one (1) or more obstructive apneas or hypopneas per hour of sleep and.Paradoxical rib cage motion during inspiration or.The caregiver observed ONE OR MORE of the following:.Labored, obstructive or paradoxical breathing or.Attended polysomnography (PSG) performed on pediatric equipment is the diagnostic test of choice for the pediatric individual because it is the only technique shown to quantify the ventilatory and sleep abnormalities associated with sleep-disordered breathing.ĭiagnosis of OSA in pediatric individuals is made when ALL of the following criteria are met:.AHI or RDI of at least 1.5 per hour with excessive daytime sleepiness, behavioral problems, or hyperactivity.Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of at least five (5) per hour or.Clinically significant OSA for pediatric individuals is defined as follows:.A pediatric individual is defined between the age of zero (0) and 17 years of age. ![]() Left untreated, OSA can result in complications, which may include neurocognitive impairment, behavioral problems, failure to thrive, or cor pulmonale, particularly in severe casesįor the purposes of this policy the treatment of OSA may be considered medically necessary when ANY of the following conditions are met: Obstructive Sleep Apnea (OSA) in pediatric individuals is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.
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