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Bank stocks led a sharp decline in early trading on Wall Street on Thursday.
JPMorgan Chase dropped after The New York Times reported that its trading loss could be $9 billion, much larger than the bank has acknowledged.
Dow plunges
The Dow Jones industrial average plunged 162 points to 12,464 in the first hour of trading.
The early slump of 1.3 per cent wiped out the Dow's gain for the week.
Investors were also punishing bank stocks because British regulators escalated their inquiry into the manipulation of a key interest rate. Citigroup, Britain's HSBC, Switzerland's UBS and the Royal Bank of Scotland were also named by British regulators in the probe.
Keywords: interest rate, LIBOR, British regulators


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Two Heded Chan of West Michigan's LiveJournal:
My friend thought he found a chan cd in someone's car but it ended up bein a rap cd. Dammit all! Where could i get a THC cd????

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text: Shapeways: Bring your creativity to life in 3D http://www.shapeways.com/forum/index.php Shapeways: Bring your creativity to life in 3D My design but not my design? http://www.shapeways.com/forum/index.php?t=rview&goto=19195&th=3701#msg_19195 http://www.shapeways.com/model/141148/turbo_rifle.html For no particular reason, I clicked it. But when I did, I noticed that at the top-right, where it would normally say "back to Drawn-Steel Hero's designs"... it actually had a link to clsn's designs. Any idea why this might be? Andy]]> Drawn-SteelHero 2010-10-15T23:36:21-00:00 Re: My design but not my design? http://www.shapeways.com/forum/index.php?t=rview&goto=19222&th=3701#msg_19222 clns's one, in my case...) A bug has to be fixed!]]> Magic 2010-10-16T13:24:44-00:00 Re: My design but not my design? http://www.shapeways.com/forum/index.php?t=rview&goto=19381&th=3701#msg_19381 Bart]]> bartv 2010-10-19T10:01:21-00:00


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Staff Reporter
Dharmapuri: Secretary to Government, Handlooms, Handicrafts, Textiles and Khadi Viswanath Shegaonkar reviewed the progress of development works taken up in various departments in a meeting at the Collectorate on Tuesday.
Collector Pankaj Kumar Bansal presided over the meeting.
Earlier, Mr. Shegaonkar inspected the progress of construction of an in-patient ward at the Morapur Primary health centre at Rs. 3 lakh.
He inspected the ambulances allotted under the Tamil Nadu Health System Project to block headquarters in the district.
Mr. Shegaonkar inspected the progress of road-laying works from Dharmapuri to Harur at Rs. 64 lakh and Gopinathampatti to Harur via Morapur to a distance of 3.4 km and widening of Dharmapuri-Morapur Road at Rs. 33 lakh.


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Win a Free Pass to LISA '10
ROSE Blog: Rikki's Open Source Exchange
I have 2 free passes to give away to LISA '10 (includes the technical program and evening events only). If you would like to win one of the free passes, here's what you have to do: Send me an email (firstname.lastname@example.com).
The catch: Your email message must be in either limerick or haiku form, and it must include the word "LISA" or "Linux Pro". The first 2 qualifying submissions will earn the budding poets a free pass to LISA '10 and a Linux Pro t-shirt (so you can arrive at LISA in style, of course). Winning submissions will also be posted here on my blog.
Happy Friday! And Happy Haikuing or Limericking!
UPDATE: Congratulations to our winners!
Julie Baumler submitted this gem:
I'd love to Lisa
So I can be a tr-ue
Linux Pro oh oh
and Jeremy Sands sent in this little beauty:
Free pass to LISA?
Nice, I'm not Daddy Warbucks.
I hate tuition.
Issue 175/2015
Buy this issue as a PDF
Code.org and College Board Team Reach Out for Talented High School Coders
New partnership will bring more and better CS training to US schools
A Peek Inside TeslaCrypt Ransomware
Criminals offer online help over Tor network
Mumblehard Still Spams
Sophisticated malware is still present on Joomla and WordPress sites around the world.
Launchpad Gets Git
Future versions of Ubuntu's code service will support the popular Git version control system used with Linux and other open source projects.
AMD Posts Code for Linux GPU Driver
New release marks the arrival of AMD's unified driver strategy.
30 Percent of New Server Equipment Goes to Cloud Infrastructure
A new study by IDC charts big changes in the big hardware market.
Windows Might Go Open Source
Azure CTO says Redmond has already considered the unthinkable.
Linux Mint Will Stay with Ubuntu
Lead developer quells rumors that the Debian version is slated for center stage.
Microsoft Frees Code for .NET Build Engine
MSBuild is now just another GitHub project as Redmond continues its path to the light.
Researchers Demonstrate Hack by Heat
Malware could pass data and commands between disconnected computers without leaving a trace on the network.


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The Pacific 10 Alliance!
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Jakes On A Plane
Join Date: Dec 2009
Posts: 404
Originally Posted by
DN is hard worker on and off the court,but he doesn't have any weapons to make it to the next step to be a #1 or prime player or pro.. I hope he can find it soon as time is running out . The YouTube of him against Klahn,I noticed he was hitting so many balls off his back foot and jumping . It's too hard to win consistently playing defense at that higher level of tennis. His volleys are good but they are not decisive put away winners ,they are more like placement volleys . He has a great mental game and knows how to fight ,but I think he's gonna need a bit more.
To be fair to Nguyen, he's 5'10. Klahn's spin, specifically on the forehand, was kicking above Daniel's head. He didn't really have much choice than to be jumping off the back foot. This was also Nguyen's first true test of the season since the fall tournaments. Not only would I love to see this matchup again at Ojai, but I definitely think the score would be closer.
There has got to be someone out there on the college tennis scene that can spin Klahn's spin.
Jakes On A Plane
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A state appellate court scrapped the 2003 sale of KOCE-TV for a second time.
The unanimous ruling "kind of left us in a big quagmire," KOCE-TV Foundation counsel Ardelle St.George said Friday.
Reaffirming a June 2005 decision setting aside the sale, the Fourth District Court of Appeal ruled on Thursday that Coast Community College District violated state law when it allowed the foundation to lower its bid after winning the contract.
But the court rejected rival bidder Daystar Television Network's plea to award the station to the Christian broadcaster.
For now, the foundation keeps Orange County's sole Public Broadcasting System affiliate. What happens next is unclear.
If no one appeals, lawyers for Daystar and the district said, the district will have to take back the station and refund the foundation's $8 million down payment.
That won't be easy. The foundation holds the all-important Federal Communications Commission broadcasting license for the station, and no state court can tell the FCC what to do. Plus, the foundation has signed several contracts - "almost two years of very, very active business dealings," foundation lawyer George Rudolph said - that could make things messy for the district.
On top of that, Dallas-based Daystar is pursuing a federal lawsuit against the district, alleging religious discrimination. Daystar attorney Richard Lloyd Sherman said it could seek $30 million or more from the district.
In short, the district faces potential claims by both the foundation and Daystar.
"It is potentially a big, big deal for the district," Rudolph said, "and precisely what the district was trying to avoid in the first place."
"They're in a very difficult position," Sherman said. "And they created the position and put themselves in it."
"Daystar wanted to be vindictive," district lawyer Milford Dahl Jr. said. "They succeeded."
The trouble started in October 2003, when the district opened bids for the station. The foundation offered $32 million - $8 million in cash plus $24 million over 10 years with interest. Daystar offered $25.1 million. One day after the bidding closed, Daystar upped its offer to $40 million.
The district board chose the foundation.
But the foundation quickly ran into problems. It came back in December 2003 with a revised deal: $8 million in cash plus $17.5 million over time without interest. The new deal had a present value of between $19.5 million and $23.5 million, the court wrote - at best $8.5 million less than the original bid and $1.6 million less than Daystar's first bid.


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I'm feeling a little sympathetic toward Ashlee Simpson these days. No, not because of her dad's outing and subsequent divorce or her parents. Or her own divorce. Or the fact that her ex-husband is now suing for full custody of their kid, or threatening to do so, if Ashlee doesn't hit rehab for her party substances addiction. But because she has to attend one of her big sister's baby showers every five months or however quickly Jessica Simpson is able to get herself pregnant again after pushing out a pup.
Still, amid it all, Ashlee managed to wear a very short dress to the girly event and flash some of her slender stems, the same ones she'll likely soon be tanning in a Malibu beachside treatment facility. Expect her to be looking even better soon, or within three more Jessica Simpson baby deliveries. Enjoy.


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Tempest Elite Marketing Launches Mobile Friendly Website
Tempest Elite Marketing have launched a new website to celebrate 2013 and better demonstrate the company's services and plans for the coming year.
Kingston Upon Hull, Yorkshire (PRWEB) January 25, 2013
Managing director of Tempest Elite Marketing, Qaysar Bhatti explains: "From listening to feedback from users of our original site, we discovered that they felt that there wasn't enough content in the site. We weren't going into as much detail about our services and how they can benefit future clients. The new format allows more content but is clear and easy to navigate."
Tempest Elite Marketing's new site features content including a services page, FAQs, a question & answer session with managing director Qaysar Bhatti, an updated mission statement and expansion plans for 2013. There are more easily accessible links to the company's social media accounts, including a new Pinterest page. "We wanted our content to be free of marketing jargon, as we want anyone to be able to access the website, whether they are potential clients, suppliers or business partners," says Qaysar Bhatti. "Our strength as a direct marketing company lies in communication, so we want the company website to reflect this by being clear and informative."
Visit the site: http://www.tempestelitemarketing.co.uk/
A key concern for the new website was to make it 'mobile-friendly'. According to research by Google, 72% of mobile users consider it important that a website is easy to use on a mobile, while 55% of users claim that a frustrating experience with a mobile site damages their image of a brand.
Tempest Elite Marketing's website has been designed so that the layout is simple to read when viewed from a mobile site. The size of the text was taken into consideration, so that information is easy to read on a small screen. Loading time on a smartphone is limited to a maximum of 5 seconds, and the buttons are large enough for use with a touchscreen; both factors considered important by Search Engine Watch in the article '72% of Consumers Want Mobile-Friendly Sites: Google Research'. To simplify the browsing process, scrolling has been limited to vertical and the page borders fit the mobile screen.
"The new website more clearly defines our vision and our ambitions for the coming year," says Tempest Elite Marketing MD Qaysar Bhatti. "We are looking to establish an international presence, especially in light of our expansion plans, and I believe that the website will help achieve this."
Tempest Elite Marketing is based in Kingston-upon-Hull. Established in 2011, the company provides outsourced direct marketing and sales solutions for national organisations.
For the original version on PRWeb visit: http://www.prweb.com/releases/prwebTempest-Elite-Marketing/Mobile-Friendly-Website/prweb10352740.htm


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Delachaux, Esker, GL Events, Vet'Affaires: French Equity Preview
Oct. 13 (Bloomberg) -- The following is a list of companies whose stocks may have unusual price changes in Paris tomorrow. Symbols are in parentheses after company names and prices are from the last close.
France's CAC 40 Index slipped 0.5 percent to 3,748.86. The SBF 120 Index lost 0.5 percent to 2,797.19.
1000mercis SA (ALMIL FP): The French Internet marketing company said its first-half net income climbed 11 percent to 3.2 million euros. The shares gained 0.3 percent to 36.09 euros.
Delachaux (DCH FP): The railway-equipment maker may be active after saying its third-quarter sales climbed 24 percent to 185.1 million euros. The company said in a statement it maintained a full-year sales forecast of "slightly more" than 700 million euros. The stock shed 0.6 percent to 58 euros.
Esker SA (ALESK FP): The software company may move after saying its third-quarter sales climbed to 7.67 million euros from 6.96 million euros. Elsker confirmed a full-year revenue growth target of more than 10 percent. The shares rose 1.4 percent to 6.74 euros.
Exel Industries (EXE FP): The spray maker said fourth-quarter revenue advanced 14 percent to 100.1 million euros. The shares were unchanged at 30.50 euros.
Fonciere Sepric (SPRIC FP): The French commercial real-estate investment and management company reported net income of 17.4 million euros for the 12 months ended June 30, compared with a loss of 11.3 million euros in the year-earlier period. The company said the results were calculated on a pro-forma basis. The stock was unchanged at 7.21 euros.
GL Events SA (GLO FP): The company that manages exhibition venues and supplies events services may be active after saying third-quarter revenue surged 46 percent to 150.7 million euros. The company said in a statement it is "confident" it can reach full-year sales of more than 690 million euros. The shares gained 0.5 percent to 23.60 euros.
Tharreau Industries (THAR FP): The non-woven textile company said it will pay out 9.96 million euros to investors in a one-time dividend of 7.50 euros per share.
Vet'Affaires SA (VET FP): The French discount clothing retailer may move after saying its third-quarter sales jumped to 41.5 million euros. The shares gained 0.4 percent to 26 euros.
To contact the reporter on this story: Albertina Torsoli in Paris at firstname.lastname@example.com
To contact the editor responsible for this story: Phil Serafino at firstname.lastname@example.com


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Obstructive sleep apnea (OSA) syndrome is characterized by repetitive episodes of upper airway obstruction due to the collapse of the upper airway during sleep. OSA is typically diagnosed by overnight monitoring with polysomnography (PSG). Medical management of OSA may include weight loss, avoidance of stimulants, body position adjustment, oral appliances, and use of continuous positive airway pressure (CPAP) during sleep.
In patients with OSA, the normal pharyngeal narrowing is accentuated by anatomic factors, such as a short, wide neck, elongated palate and uvula, or large tonsillar pillars with redundant lateral pharyngeal wall mucosa. Furthermore, OSA may be associated with a wide variety of craniofacial abnormalities, including micrognathia, retrognathia, or maxillary hypoplasia. In addition, OSA is associated with obesity. Obstruction anywhere along the upper airway can result in apnea. Therefore, OSA is associated with a heterogeneous group of anatomic variants producing obstruction.
The hallmark symptom of OSA is excessive daytime sleepiness; the hallmark clinical sign is snoring. The snoring abruptly ceases during the apneic episodes and during the brief period of patient arousal and then resumes when the patient again falls asleep. Sleep fragmentation associated with repeated arousal during sleep can lead to impairment of daytime activity. For example, adult patients with OSA-associated daytime somnolence are thought to be at higher risk for accidents involving motorized vehicles, i.e., cars, trucks, or heavy equipment. OSA in children may result in neurocognitive impairment and behavioral problems. In addition, OSA affects the cardiovascular and pulmonary systems. For example, apnea leads to periods of hypoxemia, alveolar hypoventilation, hypercapnia, and acidosis. This in turn can cause systemic hypertension, cardiac arrhythmias, pulmonary hypertension, and cor pulmonale. Systemic hypertension is common in patients with OSA. Severe OSA is also associated with decreased survival, presumably related to severe hypoxemia, hypertension, or an increase in automobile accidents related to daytime sleepiness.
In adults, OSA is often suspected on the basis of the clinical history and physical appearance; i.e., an overweight individual with a wide neck. The most common symptoms are snoring, excessive daytime sleepiness, and hypertension. Excessive daytime sleepiness may be subjective and may be assessed by questionnaires such as the Epworth Sleepiness Scale (ESS), a short self-administered questionnaire that asks patients, "How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?"
The patient rates his or her likelihood of falling asleep in these 8 different situations as: 0 (would never doze), 1 (slight chance of dozing), 2 (moderate chance of dozing), or 3 (high chance of dozing). The maximum score is 24, and a score of 10 or below is considered normal.
Daytime sleepiness may also be measured objectively with tests such as the multiple sleep latency test or the maintenance of wakefulness test. The multiple sleep latency test (MSLT) measures how quickly the patient falls asleep when instructed to relax in a quiet and dimly lit room, and the maintenance of wakefulness test measures sleep latency when the patient is instructed to attempt to remain awake in an unstimulating environment. These tests are not considered necessary to evaluate sleep apnea, but the multiple sleep latency test may be used when symptoms, including excessive daytime sleepiness, suggest narcolepsy.
Daytime sleepiness is uncommon in young children with OSA. Symptoms in children may include habitual snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems. OSA can occur in children of all ages, from neonates to adolescents. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders. In otherwise healthy children, OSA is usually associated with adenotonsillar hypertrophy and/or obesity. The first-line treatment for pediatric OSA is adenotonsillectomy.
The final diagnosis of OSA rests on a combination of clinical evaluation and objective criteria to identify those levels of obstruction that are considered to be clinically significant. The gold standard diagnostic test for sleep disorders is considered a polysomnogram, performed in a sleep laboratory. (1) A standard polysomnogram, supervised by a sleep lab technician, typically includes:
Additional parameters of sleep that are typically measured during in-lab polysomnography include:
The first three elements listed here (EEG, submental electromyogram, and electro-oculogram) are required for sleep staging. By definition, a polysomnogram always includes sleep staging, while a cardiorespiratory "sleep study" does not. The actual components of the study will be dictated by the clinical situation. Supervision of the test may be considered important to ensure that the monitors are attached appropriately to the patient and do not become dislodged during the night. In addition, an attendant can identify severe OSA so that continuous airway pressure can be instituted in the second part of the night, and the most effective level of CPAP therapy can be determined. These studies are known as "split-night" studies, in which the diagnosis of OSA is established during the first portion of the night and CPAP titration is conducted during the second portion of the night. If successful, this strategy can eliminate the need for an additional polysomnogram for CPAP titration.
Typically, the evaluation of OSA includes sleep staging to assess arousals from sleep and determination of the frequency of apneas and hypopneas from channels measuring oxygen desaturation, respiratory airflow, and respiratory effort. In adults, an obstructive apnea is defined as at least a 10-second cessation of respiration associated with ongoing ventilatory effort. Obstructive hypopnea is an equal to or greater than 30% reduction in airflow, with an associated fall in oxygen saturation (at least 4%) or arousal. (An accepted alternative definition of hypopnea is an equal to or greater than 50% reduction in airflow with equal to or greater than 3% desaturation). The AHI may also be referred to as the respiratory disturbance index (RDI). The AHI is defined as the total number of events per hour of sleep. RDI may be defined as the number of apneas, hypopneas, and respiratory event related arousals (RERAs) per hour of sleep. When sleep onset and offset are unknown (e.g., in home sleep studies), the RDI may be calculated based on the number of apneas and hypopneas per hour of recording time. A diagnosis of OSA syndrome is accepted when an adult patient has an AHI greater than 5 and symptoms of excessive daytime sleepiness or unexplained hypertension. An AHI equal to or greater than 15 is typically considered moderate OSA, while an AHI greater than 30 is considered severe OSA. Due to faster respiratory rates in children, pediatric scoring criteria define an apnea as 2 or more missed breaths, regardless of its duration in seconds. Hypopneas are scored by a 50% or greater drop in nasal airflow and either an equal to or greater than 3% decrease in oxygen saturation or an associated arousal. In pediatric patients, the presentation of OSA in children may differ from that of adults. Children frequently exhibit behavioral problems or hyperactivity rather than daytime sleepiness and an AHI greater than 1.5 is considered abnormal, and an AHI of 15 or greater is considered severe. Although there is poor correlation between AHI and OSA symptoms, an increase in mortality is associated with an AHI of greater than 15 in adults. Mortality has not been shown to be increased in adult patients with an AHI between 5 (considered normal) and 15. Sources of measurement error with polysomnography include data loss, artifact, event recognition errors, measurement errors, use of different types of leads, and night-to-night variability.
It is estimated that about 7% of adults have moderate or severe OSA, and 20% have at least mild OSA and that the referral population of OSA patients represents a small proportion of patients who have clinically significant and treatable disease. (2) In light of the limited capacity of sleep laboratories, a variety of devices have been developed specifically to evaluate OSA at home. These range from portable full polysomnography systems to single channel oximeters. Available devices evaluate different parameters, which may include oximetry, respiratory and cardiac monitoring, and sleep/wake activity, but the majority of portable monitors do not record EEG. It has been proposed that unattended studies with portable monitoring devices may improve the diagnosis and treatment of patients with OSA, although the limited number of channels in comparison with full polysomnographic recording may decrease the capability for differential diagnosis or detection of comorbid conditions.
In the current (2005) practice parameters of the American Academy of Sleep Medicine (1), there are four types of monitoring procedures:
Types 1 and 2 would be considered polysomnographic studies, and Types 3 and 4 would be considered polygraphic sleep studies. The terms sleep studies and polysomnography are often used interchangeably.
A wide variety of portable monitors and proprietary automated scoring systems are being tested and marketed, but the optimum combination of sensors and scoring algorithms is currently unknown. Current recommendations are that the portable monitoring device have four channels (oxygen saturation, respiratory effort, respiratory airflow, and heart rate) and allow review of the raw data. Type IV monitors with fewer than three channels are not recommended due to reduced diagnostic accuracy and higher failure rates. As with attended PSG, it is important that the raw data from home sleep studies be reviewed by a professional with training in sleep medicine in order to detect artifacts and data loss.
The medical professional who is interpreting a polysomnogram or home sleep study should have training in sleep medicine and should review the raw data from PSG and home sleep studies in order to detect artifacts and data loss. In addition, the treatment of patients diagnosed with OSA should be initiated and monitored by a professional with training in sleep medicine. It is important to monitor symptoms and adherence to positive airway pressure (PAP) treatment, e.g., review of symptoms and device utilization between 30 and 90 days.
Although not an exclusive list, patients with all four of the following symptoms are considered to be at high risk for OSA:
If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA, (e.g., age of the patient, male gender, thick neck, or craniofacial or upper airway soft tissue abnormalities) may be considered. Objective clinical prediction rules are being developed; however, at the present time, risk assessment is based on clinical judgment. (1, 2) Overnight oximetry has been used by some sleep specialists as a component of the risk assessment but is not adequate for the diagnosis of OSA. Therefore, a follow-up PSG or home sleep study would still be required to confirm or exclude a diagnosis of OSA.
American Academy for Sleep Medicine (AASM) Practice Parameters indicate that a split-night study (initial diagnostic polysomnography [PSG] followed by CPAP titration during PSG on the same night) is an alternative to one full night of diagnostic PSG followed by a second night of titration if the following four criteria are met (1):
The MSLT is an objective measure of the tendency to fall asleep in the absence of alerting factors, while the maintenance of wakefulness test (MWT) is an objective measure of the ability to stay awake under soporific conditions (used to assess occupational safety). (3) The MSLT and MWT are not routinely indicated in the evaluation and diagnosis of OSA or in assessment of change following treatment with CPAP. The MSLT may be indicated as part of the evaluation of patients with suspected narcolepsy to confirm the diagnosis (often characterized by cataplexy, sleep paralysis, and hypnagogic/hypnopompic hallucinations) or to differentiate between suspected idiopathic hypersomnia and narcolepsy. Narcolepsy and OSA can co-occur. (3, 4) Since it is not possible to differentiate the excessive sleepiness caused by OSA and narcolepsy, the OSA should be treated before confirming a diagnosis of narcolepsy with the MSLT.
PSG may also be performed in patients with symptoms suggestive of narcolepsy (excessive sleepiness, cataplexy, sleep paralysis, and sleep-related hallucinations), unrefreshing sleep with daytime fatigue/sleepiness but without snoring or witnessed apneas, obesity hypoventilation syndrome (obesity with poor breathing, leading to hypoxia and hypercarbia), parasomnias, periodic limb movements during sleep, sleep-related seizure disorder, and neuromuscular disorders with sleep-related symptoms. The American Academy for Sleep Medicine (AASM) has published guidelines for polysomnography and related procedures for these indications. (1)
Medical management of OSA includes weight loss, oral appliances, and various types of positive pressure therapy (i.e., fixed CPAP, bilevel positive airway pressure [BiPAP], or auto-adjusting CPAP). CPAP involves the administration of air, usually through the nose, by an external device at a fixed pressure to maintain the patency of the upper airway. Bilevel positive airway pressure is similar to CPAP, but these devices are capable of generating 2 adjustable pressure levels. Auto-adjusting CPAP adjusts the level of pressure based on the level of resistance and thus administers a lower mean level of positive pressure during the night. It has been hypothesized that both bilevel positive airway pressure and auto-adjusting CPAP are more comfortable for the patient and thus might improve patient compliance or acceptance. Oral appliances can be broadly categorized as mandibular advancing/positioning devices or tongue-retaining devices. Oral appliances can either be "off the shelf" or custom made for the patient by a dental laboratory or similar provider. A number of oral appliances have received marketing clearance through the U.S. Food and Drug Administration's (FDA) 510(k) pathway (product code LQZ) for the treatment of snoring and mild to moderate sleep apnea, including the Narval CC™, LambergSleepWell-Smarttrusion, 1st Snoring Appliance, Full Breath Sleep Appliance, PM Positioner, Snorenti, Snorex, Osap, Desra, Elastomeric Sleep Appliance, Snoremaster Snore Remedy, Snore-no-More, Napa, Snoar™ Open Airway Appliance, and The Equalizer Airway Device. In 2010, a nasal expiratory resistance valve (PROVENT, Ventus Medical) received marketing clearance 510(K) for the treatment of OSA. PROVENT is a single use device containing valves that are inserted into the nostrils and secured with adhesive.
The Winx Sleep Therapy System is an intraoral pressure gradient device that is intended for home use and proposed to treat OSA in adults. The mouthpiece is placed in the patient's mouth and worn during sleep. A gentle, negative pressure is generated from the console to hold the tongue and soft palate out of the airway. Clinicians can download patient usage data from the console and review usage of the device (62).
Actigraphy refers to the assessment of activity patterns by devices typically placed on the wrist or ankle that record body movement, which is interpreted by computer algorithms as periods of sleep and wake. Sleep/wake cycles may be altered in sleep disorders including insomnia, circadian rhythm sleep disorders, sleep-related breathing disorders, restless legs syndrome, and periodic limb movement disorder. In addition, actigraphy could potentially be used to assess sleep/wake disturbances associated with numerous other diseases or disorders such as attention-deficit/hyperactivity disorder, chronic fatigue syndrome, asthma, Parkinson's syndrome, post-surgical delirium, stroke, advanced cancer, and intensive care monitoring.
Actigraphic devices are typically placed on the non-dominant wrist with a wristband and are worn continuously for at least 24 hours. Activity is usually recorded for a period of 3 days to 2 weeks but can be collected continuously over extended time periods with regular downloading of data onto a computer. The activity monitors may also be placed on the ankle for the assessment of restless legs syndrome, or on the trunk to record movement in infants. The algorithms for detection of movement are variable among devices and may include "time above threshold," the "zero crossing method," or "digital integration" method, resulting in different sensitivities. Sensitivity settings (e.g., low, medium, high, automatic) can also be adjusted during data analysis. The digital integration method reflects both acceleration and amplitude of movement; this form of data analysis may be most commonly used today. Data on patient bed times (lights out) and rise times (lights on) are usually entered into the computer record from daily patient sleep logs or by patient-activated event markers. Proprietary software is then used to calculate periods of sleep based on the absence of detectable movement, along with movement-related periods of wake. In addition to providing graphic depiction of the activity pattern, device-specific software may analyze and report a variety of sleep parameters including sleep onset, sleep offset, sleep latency, total sleep duration, and wake after sleep onset. Actigraphy has been used for more than 2 decades as an outcome measure in sleep disorders research. Numerous actigraphy devices have received FDA approval through the 510(k) process. Actigraphy devices designed and marketed to measure physical activity might also be used to measure sleep.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Supervised polysomnography (PSG) performed in a sleep laboratory may be considered medically necessary as a diagnostic test in patients with any of the following:
Unattended (unsupervised) home sleep studies with a minimum of 4 recording channels (including oxygen saturation, respiratory movement, airflow, and electrocardiogram (EKG) or heart rate) may be considered medically necessary in adult patients who meet criteria listed above for supervised PSG and have no evidence by history and physical examination of a health condition that might alter ventilation or require alternative treatment, including any of the following:
Unattended (unsupervised) sleep studies are considered experimental, investigational and/or unproven in adult patients who are considered at low to moderate risk for OSA.
Unattended (unsupervised) sleep studies are considered experimental, investigational and unproven, in pediatric patients (i.e., younger than 18 years of age).
A repeated supervised polysomnography performed in a sleep laboratory may be considered medically necessary under the following circumstances:
NOTE: This does not imply that supervised studies are needed routinely following unattended studies.
Repeated unattended (unsupervised) home sleep studies with a minimum of four recording channels (including oxygen saturation, respiratory movement, airflow, and EKG/heart rate) may be considered medically necessary in adult patients under the following circumstances:
Multiple Sleep Latency Test (MSLT) may be considered medically necessary to confirm the diagnosis of narcolepsy on the day following a PSG if the PSG is negative for OSA.
Maintenance of Wakefulness (MWT) testing is considered experimental, investigational and/or unproven.
NOTE: In pediatric patients, an AHI greater than 1.5 is considered abnormal, and an AHI of 15 is considered severe.
NOTE: A split-night study, in which severe OSA is documented during the first portion of the study using polysomnography, followed by CPAP during the second portion of the study, can eliminate the need for a second study to titrate CPAP.
NOTE: Respiratory disturbance index may be used in place of apnea/hypopnea index (AHI) in unattended sleep studies
CPAP may be considered medically necessary in adult or pediatric patients with clinically significant OSA.
Auto-adjusting CPAP (APAP) may be considered medically necessary during a 2-week trial to initiate and titrate CPAP in adult patients with clinically significant OSA.
Bilevel positive airway pressure (BiPAP) without backup rate feature or APAP may be considered medically necessary in patients:
Bilevel positive airway pressure (BiPAP) with back-up rate feature [e.g. VPAP Adapt™ from ResMed, and BiPAP AutoSV Advanced from Respironics, Inc] may be considered medically necessary in patients:
NOTE: This medical policy only addresses BiPAP with back-up feature associated with sleep related breathing disorders. This device may be used for other diagnoses including, but not limited to, restrictive thoracic disorders, severe COPD and hypoventilation syndromes. These conditions are not addressed in this medical policy.
Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in patients with mild to moderate OSA who prefer oral appliances (OA) to CPAP, or who do not respond to CPAP, or are not appropriate candidates for CPAP, that meet all of the following conditions:
NOTE: CPAP has been shown to have greater effectiveness than oral appliances in general. This difference in efficacy is more pronounced for patients with severe OSA, as oral appliances have been shown to be less efficacious in patients with severe OSA than they are in patients with mild-moderate OSA. Therefore, it is particularly important that patients with SEVERE OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance.
Oral pressure therapy (OPT) (e.g. Winx™,Apnicure,Inc.) to treat OSA is considered experimental, investigational and/or unproven.
A nasal expiratory positive airway pressure (EPAP) device (e.g., PROVENT) is considered experimental, investigational and/or unproven.
Actigraphy is considered experimental, investigational and/or unproven for the routine diagnosis, assessments of severity, or management of any of the sleep disorders, including the insomnias, obstructive sleep apnea syndrome or periodic limb movement disorder.
NOTE: Surgical management of OSA is addressed on the policy Sleep Related Breathing Disorders: Surgical Management.
Policy Guidelines
CPT coding makes a distinction between sleep studies that do not include electroencephalographic (EEG) monitoring, and polysomnography, which includes EEG monitoring. Polysomnography is usually conducted in a sleep laboratory and attended by a technologist, but may also be conducted with Type 2 portable monitoring. The type of study is further characterized as attended (supervised) or unattended by a technologist. Home or portable monitoring implies unattended sleep studies, typically conducted in the patient's home. There is no CPT code for "unattended" polysomnography.
Cardiorespiratory sleep studies without EEG may be called polygraphic studies and can either be attended or unattended by a technologist. The CPT codes 95807 and 95806 distinguish polygraphic sleep studies that are attended or unattended, but there are no codes that distinguish between type 3 and type 4 sleep studies.
CPT E0470 is used to describe BiPAP without back-up feature.
CPT E0471 is used to describe BiPAP with back-up feature.
This policy was originally developed in 2005 and has been updated with periodic searches of scientific literature. This section of the current policy has been substantially revised. The following is a summary of the key literature to date.
As described in Cochrane reviews from 2006, treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) or oral appliances has been shown to improve objective and subjective symptoms in patients with obstructive sleep apnea. (5, 6) This policy focuses, therefore, on patient selection criteria for polysomnography (PSG), or sleep study, and the use of home sleep studies as an alternative to a supervised laboratory study. In addition, the use of expiratory positive airway pressure (EPAP), auto-adjusting CPAP (APAP) or bilevel positive airway pressure (BiPAP) in patients with OSA is reviewed.
Definition of Clinically Significant OSA: The original rationale for the diagnosis and treatment of OSA was based on epidemiologic studies that suggested increased mortality in patients with an apneic index greater than 20. However, considering that an apneic/hypopnea index (AHI) of 5 is considered normal, there is obviously a great range of severity of OSA, ranging from those with only snoring as a complication to those with associated severe excessive daytime sleepiness, hypertension, or cardiac arrhythmias. If OSA is considered mild to moderate and snoring is the only manifestation, an intervention would be considered not medically necessary. For example, pronounced snoring may be considered predominantly a social annoyance to the patient's bed partner with no impact on the patient him/herself.
In 2011, the Agency for Healthcare Research and Quality (AHRQ) conducted a comparative effectiveness review (CER) on the diagnosis and treatment of OSA in adults. (7) The CER found strong evidence that an AHI greater than 30 events/hour is an independent predictor of all-cause mortality, with low or insufficient evidence for an association between AHI and other clinical outcomes. The CER found moderate evidence that type 3 and type 4 monitors may have the ability to accurately predict AHI suggestive of OSA and that type 3 monitors perform better than type 4 monitors at AHI cutoffs of 5, 10, and 15 events per hour. Despite no or weak evidence for an effect of CPAP on clinical outcomes, given the large magnitude of effect on the intermediate outcomes of AHI, Epworth Sleepiness Scale (ESS), and arousal index, the strength of evidence that CPAP is an effective treatment to alleviate sleep apnea signs and symptoms was rated moderate. The strength of the evidence that mandibular advancement devices improve sleep apnea signs and symptoms was rated moderate, and there was moderate evidence that CPAP is superior to mandibular advancement devices in improving sleep study measures.
Attended polysomnography (PSG) has been considered the gold standard in the diagnosis and treatment of OSA. In 2007, AHRQ conducted a technology assessment on portable monitoring for the Medicare Evidence Development and Coverage Committee (MedCAC). (8)
The report concluded:
In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a national coverage decision allowing an initial 12-week period of CPAP based on a clinical evaluation and a positive sleep test performed with either an attended PSG performed in a sleep laboratory or an unattended home sleep test with a device that measures at least three channels. (9) Previously, coverage for CPAP required determination of AHI from attended PSG in a sleep laboratory, effectively establishing PSG-defined AHI as the only acceptable measure of OSA. As indicated in the AHRQ report, there is a poor correlation between AHI and daytime sleepiness, as well as between improvement in AHI and improvement of symptoms with CPAP usage. In addition, effectiveness of CPAP is affected by tolerance to the device (mask and airway pressure) and ultimately by compliance with treatment. These issues raise the question of whether PSG-defined AHI and manual titration of CPAP should remain the only means for diagnosis and treatment of OSA. Therefore, this policy evaluates the literature on the clinical utility of portable monitoring devices to identify patients with a high likelihood of benefit from treatment, without increasing potential harm from misdiagnosis.
Mulgrew et al. published a randomized validation study of the diagnosis and management of OSA with a single channel monitor followed by APAP. (10) They developed a diagnostic algorithm (Epworth Sleepiness Scale [ESS] score greater than 10, Sleep Apnea Clinical Score of 15 or greater, and a respiratory disturbance index [RDI] of 15 or greater on overnight oximetry) that was found to have a 94% positive predictive value for moderate to severe OSA assessed by PSG. Patients who passed the screening (n=68) were randomized to either attended in-laboratory PSG with CPAP titration or to home monitoring with a portable APAP unit. Home monitoring consisted of autotitration for 1 week, followed by download and assessment of efficacy data for the week (i.e., CPAP, mask leak, residual respiratory events, and use) and determination of the pressure for CPAP by the study physician. A second assessment of efficacy data was conducted for a week of CPAP use, and the pressure setting was adjusted by the CPAP coordinator in conjunction with the study physician. After 3 months of CPAP use, the subjects returned to the laboratory for PSG (with CPAP); no difference was observed between lab-PSG and home-managed patients in any of the outcome measures (median AHI of 3.2 vs. 2.5, median ESS of 5.0 vs. 5.0, and Sleep Apnea Quality-of-Life Index of 5.5 vs. 5.8, all respectively). Another study assessed the clinical utility of home oximetry in comparison with PSG by measuring the accuracy with which sleep physicians could predict which patients would benefit from treatment of OSA. (11) The primary outcome measure was the change in sleep apnea-specific quality of life after treatment. Subjects were randomly selected from a pool of referred patients; 307 were randomized, and 288 began a trial of CPAP. An additional 51 patients (18%) quit before the end of the 4-week CPAP trial; 31 indicated that they had trouble sleeping with CPAP, 3 removed the mask in their sleep, and 2 had nasal or sinus congestion. Overall, physicians predicted success in 50% of patients and 42% met the criterion for improvement. Outcomes of treatment were similar in the 2 groups, with improvements in ESS scores of 3.4 for home monitoring and 4.0 for PSG. The ability of physicians to predict the outcome of treatment was similar for the 2 methods. Five cases (2%) required PSG for diagnosis of other nonrespiratory sleep disorders (narcolepsy, periodic leg movements, and idiopathic hypersomnolence).
Skomro et al. conducted a randomized trial (102 patients) of home testing followed by 1 week of APAP, compared with in-laboratory PSG followed by CPAP titration. (12) The study included adult patients with suspected OSA who had been referred to participating sleep medicine physicians at a tertiary sleep disorders clinic. Patients were included in the study if they had at least 2 symptoms of OSA (ESS >10, witnessed apneas, or snoring). The average ESS at baseline was 12.5. Exclusion criteria were respiratory or heart failure, clinical features of another sleep disorder, use of hypnotics, upper airway surgery, CPAP or oxygen therapy, pregnancy, or a safety-sensitive occupation. For home testing, a type 3 monitor was used that measured airflow, respiratory effort, oxygen saturation, heart rate, and body position, and home studies with technical failures or less than 4 hours of recording were repeated (17% of patients). After completion of testing and before application of APAP/CPAP, the subjects also underwent the other sleep test (home or laboratory). All studies were scored manually by a technician and reviewed by a sleep medicine physician, and subjects and investigators were blinded to the results of the second test. After sleep testing, 89 subjects received a diagnosis of OSA and were prescribed CPAP; 10 of those patients rejected CPAP treatment. In the home monitoring group, the proportion of subjects with an AHI greater than 30 was significantly lower, and the APAP-derived CPAP pressure was significantly higher than the manually-titrated CPAP pressure from the laboratory study. After 4 weeks of therapy, there were no significant differences between laboratory and home monitoring groups on any of the outcome measures; daytime sleepiness measured by the ESS (6.4 vs. 6.5), sleep quality measured by the Pittsburgh Sleep Quality Index (5.4 vs. 6.2), quality of life (4.5 vs. 4.6), Short-Form 36 (SF-36) Health Survey (62.2 vs. 64.1), blood pressure (129/84 vs. 125/81), or CPAP adherence (5.6 h/night vs. 5.4 h/night – all respectively).
Senn and colleagues assessed whether an empiric approach, using only a 2-week trial of APAP, could be effective for the diagnosis of OSA. (13) Patients (n=76) were included in the study if they had been referred by primary care physicians for evaluation of suspected OSA, were habitual snorers, complained of daytime sleepiness, and had an ESS score of 8 or greater (mean of 13.6). Exclusion criteria were contraindications to CPAP or APAP (heart failure, lung disease, obesity, hypoventilation syndrome), previous diagnosis or treatments of a sleep disorder, or a diagnosis of an internal medical, neurologic, or psychiatric disorder explaining the symptoms. At the end of the 2-week trial, patients were asked to rate the perceived effect of treatment and to indicate whether they had used CPAP for more than 2 hours per night and were willing to continue treatment. Patients without a clear benefit of CPAP received further evaluation including clinical assessment and PSG. Compared with PSG, patient responses showed sensitivity of 80%, specificity of 97%, and positive and negative predictive values of 97% and 78%, respectively.
Garcia-Diaz and colleagues assessed the sensitivity and specificity of home respiratory polygraphy and actigraphy to diagnose OSA in relation to laboratory PSG. (14) The cohort consisted of 65 consecutive patients referred to the sleep laboratory for PSG because of suspected OSA. Using an AHI cutoff of 15 or more, 2 independent evaluators were found to identify PSG-defined OSA in 90% to 92% of the patients (sensitivity of 84–88% and specificity of 97%). Analysis of data from the Swiss respiratory polygraphy registry found that in patients selected for portable monitoring (based on high clinical suspicion of OSA by licensed pulmonary physicians by a combination of hypersomnia, snoring, or observed apneas), confirmation or exclusion of sleep disordered breathing was possible in 96% of the 8,865 diagnostic sleep studies. (15) From these type 3 studies (four channels including airflow and respiratory movement, heart rate or electrocardiogram [ECG], and oxygen saturation), 3.5% were not conclusive and required additional PSG.
Peripheral Arterial Tone
In 2009, CMS issued a coverage decision to accept use of a sleep testing device that included actigraphy, oximetry, and peripheral arterial tone to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA. (16) A literature review of this technology in September 2009 identified a review of use of peripheral arterial tone for detecting sleep disordered breathing. (17) This review includes the critical evaluation of a number of studies comparing the Watch-PAT™ (a portable monitoring device for at-home use) with laboratory-based PSG. Relevant studies that included appropriate study populations (patients referred for evaluation of OSA or following CPAP treatment) are described.
Berry and colleagues randomized 106 patients who had been referred for a sleep study for suspected OSA at a local Veterans Administration center to portable monitoring followed by APAP (PM-APAP) or to PSG for diagnosis and treatment. (18) Patients were screened with a detailed sleep and medical history questionnaire including an ESS. To be included in the study, patients had to have an ESS score of 12 or greater and the presence of at least 2 of the following: loud habitual snoring, witnessed apnea/gasping, or treatment for hypertension. Patients on alpha-blockers or not in sinus rhythm were excluded due to the type of portable monitoring device used (Watch-PAT™ 100), which records sympathetic changes in peripheral arterial tone, heart rate, pulse oximetry, and actigraphy. Also excluded were patients with moderate to severe heart failure, use of nocturnal oxygen, chronic obstructive pulmonary disease, awake hypercapnia, neuromuscular disease, cataplexy, restless leg syndrome, use of narcotics, psychiatric disorder, shift work, or a prior diagnostic study or treatment. Of the 53 patients randomized to PSG, 6 (11%) did not have PSG-defined OSA; 43 of 49 patients (88%) with CPAP titrations started on CPAP. In the portable monitoring arm, 4 of 53 patients (8%) were found not to have OSA. A physician affiliated with the sleep research laboratory reviewed the tracings for technical quality to determine if the events were correctly identified by the analysis program. Four studies (8%) were repeated due to technical failure or insufficient sleep. Patients with negative studies were then crossed over, which identified an additional 2 patients from the PSG arm as having OSA and 1 patient from the PM-APAP arm as having OSA. These patients (total of 50) had at least 1 APAP titration, 45 of the 50 (90%) had an adequate APAP titration and accepted treatment. Adherence was similar in the two groups, with 91% of patients in the PSG arm and 89% of patients in the PM-APAP arm continuing treatment at 6 weeks. Treatment outcomes were similar in the two groups, with a 7-point improvement in ESS score, 3-point improvement in the Functional Outcomes of Sleep Questionnaire, and a machine estimate of residual AHI of 3.5 in the PM-APAP group and 5.3 in the PSG group.
Pittman et al. evaluated residual OSA in 70 patients who had self-reported adherence to CPAP for at least 3 months. (19) Exclusion criteria for the study were diagnosis of periodic leg movement disorder, RDI less than 20 on diagnostic PSG, history of peripheral vascular disease, peripheral neuropathy, nonsinus cardiac rhythm, permanent pacemaker, severe lung disease, bilateral cervical or thoracic sympathectomy, finger deformity precluding sensor application, and use of alpha-adrenergic blockers. Compared to concurrently recorded PSG, the area under the curve (AUC) from receiver-operator characteristic (ROC) analysis for RDI greater than 15 was 0.95 (85% sensitivity and 90% specificity). Specificity decreased dramatically at lower cutoffs (67% for RDI >10 and 47% for an RDI >5). Another small study of 37 consecutive patients referred to a sleep center for OSA reported a high correlation between PSG and concurrently recorded Watch-PAT RDI (r=0.93). (20) (Correlation coefficients are not considered to be as meaningful as estimates of sensitivity and specificity.) Sensitivities for AHIs greater than 5, 15, and 35 in this study were 94%, 96%, and 83%, respectively. Specificity was reported at 80%, 79%, and 72%, respectively, for these thresholds. Penzel and colleagues raised concern about the specificity of this device in an independently conducted small study of 21 patients with suspected sleep apnea. (21) The study found that for 16 of the 17 subjects with adequate recordings, the number of Watch-PAT events was greater than the number of respiratory events. The device was found to have reasonable reliability and to be very sensitive to arousal, although since arousals are not unique to apnea events, the authors concluded that the specificity of the Watch-PAT is limited. The long list of exclusion criteria in company-sponsored trials also raises questions about the clinical utility of the indirect measure of peripheral arterial tone in place of directly measuring airflow and respiratory effort. In a 2004 report, Pittman and colleagues noted other potential disadvantages of the Watch-PAT, including the inability to differentiate between the type of respiratory event (e.g., obstructive, central, mixed, or hypopnea) or to identify body position, and susceptibility to artifact from arrhythmias. (22) In this study, 28% of the cases did not achieve concordance (defined as both Watch-PAT and PSG RDI of >40 per hour, or within 10 events per hour in patients with an RDI <40 per hour). It is noteworthy that the American Academy of Sleep Medicine (AASM) has not changed their 2007 guidelines, recommending that portable monitors should minimally record airflow, respiratory effort, and blood oxygenation, using biosensors conventionally used for in-laboratory PSG. (23) At this time, evidence is insufficient to support a change in the sensors required for portable monitoring.
Maintenance of Wakefulness (MWT) testing
The utility of Maintenance of Wakefulness Testing, in terms of improved health outcomes, has not been established. The 2005 AASM Practice Parameters note there are no standard or generally accepted guidelines for the performance of a MWT, and several variations in protocol exist, based on differences in definitions of sleep onset, trial duration and the need for previous night polysomnography. Normative data, sensitivity and specificity data in various patient groups are also lacking. Nevertheless, one suggested use has been testing an individual's ability to stay awake when public or personal safety issues are involved. However, the predictive value of MWT in this setting has not been established, and test results may not translate into behavior in workplace situations. Another potential use might be assessing the response to various treatments for disorders, such as sleep apnea or narcolepsy. However there are no established levels to indicate what represents a significant change in the test findings. Also, it is unclear that testing would provide useful information, over and above the patient's clinical response to therapy in these disorders, or would influence clinical decision-making, thereby improving patient health outcomes. The AASM concludes, "Future research is needed to define normative values using rigorous methods, to identify the impact of a standard clinical protocol for MWT, and to correlate the degree of sleepiness on objective testing with safety and occupational risks for the individual and for society in 'real life' circumstances."
BiPAP and APAP
A 1995 study by Reeves-Hoche et al. randomized patients with OSA to receive either CPAP or BiPAP. (24) The authors found that patient complaints and effective use were similar in both groups but that the dropout rate was significantly higher in the CPAP group. This study suggests that BiPAP should be limited to those patients who have failed a prior trial of CPAP. The 2011 AHRQ CER found moderate evidence that APAP and fixed pressure CPAP result in similar levels of compliance (hours used per night) and treatment effects for patients with OSA. (7) Evidence-based guidelines from the AASM concluded that CPAP and APAP devices have similar outcomes in terms of AHI, oxygen saturation, and arousals. (25-28) As indicated in the 2011 AHRQ CER, increased compliance with APAP devices has not been well-documented in clinical trials. (29-31) Thus, the issues associated with APAP are similar to BiPAP; i.e., APAP may be considered medically necessary in patients who have failed a prior trial of CPAP. In addition to the studies (described previously) that used unattended APAP devices to titrate CPAP pressure, 2007 AASM practice parameters on autotitration identified 5 randomized trials supporting the use of unattended APAP to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities affecting respiration. (28) This new practice parameter was considered an option (uncertain clinical use), with automatic titration or treatment requiring close clinical follow-up (standard). The practice parameters for the use of APAP issued by the AASM point out that results may vary with different APAP devices based on different underlying technologies, and thus caution must be exercised in selecting a particular device for use. (25-28)
Nasal Expiratory Positive Airway Pressure (EPAP)
One randomized controlled trial and several prospective case series have been published with the PROVENT device.
In 2011, Berry et al. reported an industry-sponsored multicenter double-blind randomized sham-controlled trial of nasal EPAP. (32) Two-hundred and fifty patients with OSA and an AHI of 10 or more per hour were randomized to nasal EPAP (n=127) or a sham device (n=123) for 3 months. PSG was performed on 2 nights (device-on, device off, in a random order) at week 1 (92% follow-up) and after 3 months of treatment (78% follow-up). EPAP reduced the AHI from a median of 13.8 to 5.0 (-52.7%) at week 1 and from 14.4 to 5.6 (-42.7%) at 3 months. This was a significantly greater reduction in AHI than the sham group (-7.3% at week 1 and -10.1% at 3 months). Over 3 months, the decrease in ESS was statistically greater in the EPAP group (from 9.9 to 7.2) than in the sham group (from 9.6 to 8.3), although the clinical significance of a 1 point difference in the ESS is unclear. Treatment success and oxygenation data were presented only for the 58% of per-protocol patients who had an AHI of 5 or more per hour on the device-off PSG night. The oxygenation results (oxygenation desaturation index and % of total sleep time with SpO2 <90%) showed small but statistically significant decreases at 1 week and 3 months. Treatment success, defined as a 50% or greater reduction in the AHI or an AHI reduced to less than 10 (if device-off AHI was 10 or more), was greater in the EPAP group at 1 week (62% vs. 27.2%) and 3 months (50.7% vs. 22.4%). Device-related adverse events were reported by 45% of patients in the EPAP group and 34% of patients in the sham group, with 7% of patients in the EPAP group discontinuing the study due to adverse events. Overall, the validity of these results is limited by the high dropout rate, and the clinical significance of the results is uncertain.
An open-label extension of the 2011 randomized study by Berry et al. evaluated 12-month safety and durability of the treatment response in patients who had an initial favorable response to EPAP. (33) Included were 41 patients (32% of 127) in the EPAP arm of the study who used the device for an average of at least 4 hours per night on at least 5 nights per week during months 1 and 2 and had at least a 50% reduction in AHI, or reduction to less than 10 events per hour, compared to the device-off PSG. Of the 51 patients (40% of 127) eligible, 41 enrolled in the extension study, and 34 (27% of 127) were still using the EPAP device at the end of 12 months. Median AHI was reduced from 15.7 to 4.7 events per hour; the percentage of patients who met criteria for success was not reported. The arousal index was modestly decreased (from 23.9 to 19.0). Over 12 months of treatment, the ESS decreased from 11.1 to 6.0. The median percentage of reported nights used (entire night) was 89.3%. Device-related adverse events were reported by 42% of patients, and the most frequently reported adverse events were difficulty exhaling, nasal discomfort, dry mouth, headache, and insomnia. This open-label extension study is limited by the inclusion of responders only and by the potential for a placebo effect on the ESS. However, the data suggest that some patients may respond to this device, and the patient compliance data might indicate a positive effect on daytime sleepiness that leads to continued use of the device in about 1 in 4 patients. Additional controlled studies are needed to distinguish between these alternatives.
Oral Pressure Therapy (OPT)
Farid-Moayer, Siegel, et al. conducted a feasibility study of OPT for the treatment of OSA. In this single-center, proof-of-concept, single-treatment-night study, subjects with OSA underwent a baseline PSG study followed by PSG during use of an OPT system. The study included 54 men and 17 women, aged 53.2 ± 11.5 years (mean ± SD) had a baseline apnea-hypopnea index (AHI) greater than 5 events per hour. Results reported by the authors included that OPT was generally well tolerated with no serious adverse events. AHI decreased from 34.4 ± 28.9 events per hour (mean ± SD) at baseline to 20.7 ± 23.3 (p < 0.001). Treatment produced an AHI less than 10 in 48% of the subjects. The authors included that OPT significantly improved oxygen desaturation index (p < 0.001) and increased the percentage of the night with oxygen saturation of 90% or greater (p = 0.028). Stage-N1 sleep shifts, total sleep-stage shifts, awakenings and the percentage of sleep time spent in N1 sleep were significantly reduced with treatment. The authors concluded that OPT shows promise as a new treatment option for OSA in appropriate patients (63).
Current literature indicates that evaluation of OSA should be by clinical evaluation and overnight monitoring, either by attended PSG or by portable unattended home monitoring under qualified supervision and that this may be followed by a trial of APAP to evaluate efficacy and adjust pressure.
Although evidence indicates that portable monitoring can be a safe and effective method to evaluate OSA, the variety of portable monitoring devices available and the lack of standardization remains problematic. Additional study is needed to determine the most reliable types of devices and combinations of sensors. Questions also remain about the specific training of the medical personnel required to diagnose OSA without increasing risk of misdiagnosis. Based on the current evidence, use of portable monitoring may be considered medically necessary in adult patients considered to be at high risk for OSA, with clinical evaluation and follow-up conducted by a medical professional experienced in the diagnosis and treatment of sleep disorders.
Use of the novel EPAP device has been reported in several prospective case series and one industry-sponsored randomized controlled trial. The main finding of this study was a decrease in AHI with minor impact on oxygenation and the ESS. Evidence at this time is insufficient to permit conclusions regarding the effect of this technology on health outcomes.
Due to the limited number of patients in the OPT feasibility study and no long term results, the clinical significance of the results is uncertain, therefore OPT is considered experimental, investigational and unproven.
Practice Guidelines and Position Statements
The patient selection criteria for a PSG or sleep study require an estimate of the pretest probability of OSA, based on the signs and symptoms of OSA. Ideally, one would like to know the necessity of a PSG (i.e., with electroencephalography [EEG]) versus a sleep study (without EEG). A detailed analysis of these issues is beyond the scope of this policy. However, in 1997 the American Sleep Disorders Association (now the AASM) published practice parameters for PSG and related procedures; these were most recently updated in 2005. (1, 34) The guidelines suggested that patients had a 70% likelihood of having an AHI index of at least 10 if all of the following were present: habitual snoring, excessive daytime sleepiness, a body mass index greater than 35, and observed apneas. In 2005, full-night PSG was recommended for the diagnosis of sleep-related breathing disorders and for PAP titration in patients with an RDI of at least 15 per hour, or with an RDI of at least 5 per hour in a patient with excessive daytime sleepiness. (1) For patients in the high-pretest-probability stratification group, an attended cardiorespiratory sleep study (type 3 with respiratory effort, airflow, arterial oxygen saturation, and electrocardiogram [ECG] or heart rate) was considered an acceptable alternative to full-night PSG, provided that repeat testing with full-night PSG was permitted for symptomatic patients who had a negative cardiorespiratory sleep study finding. In their 2005 Guidelines, AASM stated that data were insufficient to support unattended portable sleep studies, but they might be considered acceptable when the patient has severe symptoms requiring immediate treatment and PSG is not available, the patient cannot be studied in a sleep laboratory (i.e., nonambulatory), or for follow-up studies to evaluate response to therapy. (1) The document further stated that, in these patients, a sleep study may be an acceptable alternative to PSG. However, a sleep study may only "rule in" disease, and PSG should be available for patients with false-negative sleep study results. An additional recommendation of note is that sleep studies were not recommended in patients with comorbid conditions or secondary sleep complaints. Most of the literature reviewed specifically excluded patients with comorbid conditions. A cardiorespiratory sleep study without EEG recording was not recommended for CPAP titration, as sleep staging was considered necessary. Finally, practice parameters stated that a multiple sleep latency test is not routinely indicated for most patients with sleep-related breathing disorders.
Portable monitoring (PM) devices were addressed by a joint project of the AASM, the American Thoracic Society, and the American College of Chest Physicians in 2003. (35, 36) In 2007 the AASM issued revised guidelines for the use of unattended portable monitors, recommending that portable monitors should minimally record airflow, respiratory effort, and blood oxygenation, with biosensors conventionally used for in-laboratory PSG, and that testing be performed by an experienced sleep technologist and scored by a board-certified sleep medicine specialist under the auspices of an AASM-accredited comprehensive sleep medicine program. (23)
Evidence-based guidelines on BiPAP, APAP, and dental appliances have been published by the AASM. (25-28) The Practice Parameters provided a recommendation of "guideline" (moderate clinical certainty) that although not as efficacious as CPAP, oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep-position change. Patients with severe OSA should have an initial trial of nasal CPAP because greater effectiveness has been shown with this intervention than with the use of oral appliances. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures. There was moderate clinical certainty that BiPAP was appropriate as an optional therapy in some cases in which high pressure is needed and the patient experiences difficulty exhaling against a fixed pressure or coexisting central hypoventilation present. (37) APAP was not recommended to diagnose OSA, for split-night studies or for patients with heart failure, significant lung disease such as chronic obstructive pulmonary disease, patients expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome), patients who do not snore, and patients who have central sleep apnea syndromes. (28) Unattended APAP in patients without significant comorbidities was considered an option (uncertain clinical use). The guidelines indicated that patients being treated on the basis of APAP titration must have close clinical follow-up to determine treatment effectiveness and safety, especially during the first few weeks of PAP use, and a re-evaluation and, if necessary, a standard CPAP titration should be performed if symptoms do not resolve or if the APAP treatment otherwise appears to lack efficacy.
The AASM published evidence-based guidelines for respiratory indications for polysomnography in children in 2011. (38) "Standard" recommendations were made for the following: PSG in children should be performed and interpreted in accordance with the AASM Manual for the Scoring of Sleep and Associated Events; PSG is indicated when the clinical assessment suggests the diagnosis of OSA in children; children with mild OSA preoperatively should have clinical evaluation following adenotonsillectomy to assess for residual symptoms. If there are residual symptoms of OSA, PSG should be performed; PSG is indicated following adenotonsillectomy to assess for residual OSA in children with preoperative evidence for moderate to severe OSA, obesity, craniofacial anomalies that obstruct the upper airway, and neurologic disorders; PSG is indicated for positive airway pressure titration in children with OSA.
The American Academy of Otolaryngology – Head and Neck Surgery published clinical practice guidelines on PSG for sleep-disordered breathing prior to tonsillectomy in children in 2011. (39) The committee made the following recommendations: before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for PSG if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses; the clinician should advocate for PSG prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed above for whom the need for surgery is uncertain or when there is discordance between tonsillar size of physical examination and the reported severity of sleep-disordered breathing; clinicians should communicate PSG results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy; clinicians should admit children with OSA documented on PSG for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 years or have severe OSA (AHI of 10 or more, oxygen saturation nadir less than 80%, or both); in children for whom PSG is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based PSG, when available.
The American Academy of Pediatrics (AAP) published a 2002 guideline on the diagnosis and management of uncomplicated childhood OSA associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child treated in the primary care setting; complex high-risk patients should be referred to a specialist. (40) The AAP guidelines stated that diagnostic evaluation is useful in discriminating between primary snoring and OSA; although the gold standard is overnight PSG, other diagnostic tests such as PSG of daytime naps or home oximetry may be useful if results are positive. Adenotonsillectomy is the first line of treatment for most children, and CPAP is an option for those who are not candidates for surgery or do not respond to surgery; patients should be reevaluated post-operatively to determine whether additional treatment is required. No updates of this guideline have been identified.
In 2008 the United Kingdom's National Institute for Health and Clinical Excellence (NICE) issued guidance on CPAP treatment of OSA, based on a review of the literature and expert opinion. (41) The recommendations included:
This section of the medical policy was initially based primarily on 2003 practice parameters issued by the AASM. (44) Since all the specific clinical indications for actigraphy were classified as guidelines or options, the AASM practice parameters indicated that all indications for actigraphy would be considered investigational. In a review paper that served as the basis for the 2003 practice parameters, (45) AASM pointed out the challenges in evaluating the diagnostic performance of actigraphy:
The 2005 Update for the AASM Practice Parameters (46) continued to list actigraphy as an option and suggested areas such as restless legs syndrome and characterizing circadian rhythm patterns for further evaluation. No controlled studies had been conducted to compare the results of actigraphy to other methods to determine if actigraphy would provide incremental information that would result in improved health outcomes.
In 2007 the AASM published updated practice parameters on the use of actigraphy in the assessment of sleep and sleep disorders. (47) Whereas the 2005 practice parameters focused on the comparison of actigraphy with polysomnographically recorded sleep, the 2007 update included 108 additional studies comparing actigraphy to a number of standard clinical assessment tools that included sleep logs, subjective questionnaires, caregiver reports, and circadian phase markers. Actigraphy was recommended as a "standard" only as a method to estimate total sleep time in patients with obstructive sleep apnea syndrome when PSG is not available. Other indications changed from "option" to "guideline" but failed to reach a recommendation of "standard" due primarily to the absence of high-quality trials. Few of the studies reviewed had provided technical details related to the administration and scoring of actigraphy. In addition, most of the studies lacked a description of blinding, and there was "an inadequate description of whether visual inspection of data is performed, how missing data is handled, and other important decisions made in the analysis of actigraphy data." The AASM Standards of Practice Committee indicated the need for additional research in the following areas:
In AASM's 2007 Practice Parameter on evaluation and treatment of circadian rhythm sleep disorders (CRSDs), the use of actigraphy was considered as either an option or guideline, depending on the suspected disorder. (48) Specifically, use of actigraphy was recommended as an option for diagnosis of irregular sleep-wake disorder and free-running disorder and as a guideline for diagnosis of advanced sleep phase disorder, delayed sleep phase disorder, and shift work disorder. The evidence reviewed indicated good agreement between actigraphy and results of other diagnostic tools including polysomnography, sleep logs, and markers of circadian phase. It should be noted, however, that there is a relative lack of evidence for any procedure in the diagnosis or evaluation of treatment of CRSDs. For example, use of sleep logs received a guideline recommendation, based primarily on consensus and inclusion in the second edition of the International Classification of Sleep Disorders (ICSD-2). Insufficient evidence was found to recommend use of circadian phase markers for any CRSDs other than free-running disorder. Polysomnography is not routinely indicated for the diagnosis of CRSDs. (48)
Literature Review
Actigraphy is frequently used as an intermediate outcome in research studies. However, literature review updates have not identified any studies that evaluated whether the use of actigraphy would result in improved health outcomes for patients with sleep disorders (clinical utility). A number of studies have assessed sensitivity and specificity in either healthy or clinical populations (clinical validity). Following is a description of key studies to date.
Paquet et al. compared actigraphic assessment of sleep and wake with PSG under varying conditions of sleep disturbance (night time sleep, daytime sleep, daytime sleep with caffeine) in 23 healthy subjects. (49) Data were analyzed from a study that evaluated the effects of caffeine on daytime recovery sleep. The experimental protocol involved 2 visits to the sleep laboratory, each including one night of nocturnal sleep, one night of sleep deprivation, and the next day of recovery sleep (once with placebo and once with 200 mg caffeine). The Actiwatch® and PSG equipment were synchronized prior to recording, and assessment of sleep and wake were compared for each 1-minute interval to evaluate sensitivity, specificity, and accuracy of actigraphy in comparison with manually staged sleep from PSG recordings. Sensitivity was defined as the proportion of all epochs scored as sleep by PSG that were also scored as sleep by actigraphy. Specificity was the proportion of all epochs scored as wake by PSG that were also scored as wake by actigraphy. Accuracy was the proportion of all epochs correctly identified by actigraphy. Four different sensitivity settings/scoring algorithms were compared. In general, as the threshold to detect movement was raised, sensitivity to detect sleep increased, but the ability to detect wake (specificity) decreased. With the medium threshold algorithm, the sensitivity to detect sleep was 95–96%. However specificity, or the ability to detect wake, was 54% for night time sleep, 45% for daytime recovery sleep, and 37% for daytime recovery sleep with caffeine. A main finding of the study was that the more disturbed the sleep, the less the actigraph was able to differentiate between true sleep and quiet wakefulness, with an accuracy of 72% for the most disrupted sleep condition. Through experimental manipulation of the level of sleep disturbance, this study provides substantial information about the limitations of this technology for clinical populations with sleep disruption.
Several studies assessed clinical validity in patients with primary or secondary sleep disorders. A 2006 study assessed the sensitivity and specificity of actigraphy in comparison with PSG in older adults treated for chronic primary insomnia. (50) Visual scoring of the PSG data was blinded, and actigraphic records were scored by proprietary software. The study found that actigraphy agreed with PSG scoring of sleep for 95% of the 30-second epochs (sensitivity), but agreed with PSG scoring of wake only 36% of the time (specificity). The authors concluded that, "the clinical utility of actigraphy is still suboptimal in older adults treated for chronic primary insomnia."
Beecroft et al. reported an observational study of sleep monitoring in the intensive care unit, comparing nurse assessment, actigraphy, and PSG in 12 stable, critically ill, mechanically ventilated patients. (51) PSG showed severely disrupted sleep, with decreased total sleep time and sleep efficiency, high frequency of arousals and awakenings (fragmentation), and abnormal sleep architecture (decreased slow wave and rapid eye movement [REM] sleep). Both the nurse's and the actigraphic assessment of sleep were found to be inaccurate. Actigraphy overestimated the total sleep time, with a median that was 2–3 hours greater than PSG. Median sleep efficiency (actual sleep as a percentage of total recording time) was estimated at 61–95% by actigraphy, depending on the sensitivity setting, which was substantially higher than the 42% median sleep efficiency shown by PSG with sleep staging. Actigraphy with a SOMNOwatch™ in patients (n=28) with sleep-disordered breathing showed a sensitivity of 90%, a specificity of 95%, and overall accuracy of 86% in comparison with PSG. (52) Correlations were high for total sleep time (0.89), sleep period time (0.91), and sleep latency (0.89), and moderate for sleep efficiency (0.71) and sustained sleep efficiency (0.65).
Studies continue to assess different modes of data collection and analysis, including varying the sensitivity settings for existing algorithms and developing new scoring algorithms. A 2011 publication compared 3 collection modes (proportional integration, time above threshold, and zero crossings) with PSG in 889 older community-dwelling men who participated in the Outcomes of Sleep Disorders in Men (MrOS) study. (53) The proportional integration mode was found to correspond best to PSG, with moderate interclass correlation coefficients of 0.32 to 0.57. Actigraphy in this mode overestimated total sleep time by an average of 13.2 minutes, with an absolute difference (positive or negative direction) of 52.9 minutes. There was a systematic bias for overestimating total sleep time which increased with decreasing sleep duration.
Werner and colleagues assessed agreement between actigraphy and parent diary or questionnaire for sleep patterns in 50 children, aged 4–7 years, recruited from kindergarten schools in Switzerland. Sixty-eight families agreed to participate of 660 families invited (10%). (54) Each child was home-monitored with an actigraph for 6 to 8 consecutive nights, and parents were requested to complete a detailed sleep diary (15-minute intervals) during the monitoring days to indicate bedtime, estimated sleep start, wake periods during the night, and estimated sleep end. Parents' assessment of habitual wake time, get up time, bedtime, time of lights off, sleep latency, and nap duration were obtained through questionnaire. Satisfactory agreement, defined a priori as differences smaller than 30 minutes, was achieved between actigraphy and diary for sleep start, sleep end, and assumed sleep. Actual sleep time and nocturnal wake time differed by an average of 72 minutes and 55 minutes, respectively. Satisfactory agreement was not reached between actigraphy and questionnaire for any of the parameters. The authors concluded that the diary is a cost-effective and valid source of information about children's sleep-schedule time, while actigraphy may provide additional information about nocturnal wake time or may be used if parents are unable to report in detail. Compliance and accuracy in the diaries is likely to be affected by the motivation of the parents, who in this study were self-selected.
In 2011, O'Driscoll et al. reported a comparison of actigraphy with PSG in 130 children who had been referred for assessment of sleep-disordered breathing. (55) The arousal index and apnea-hypopnea index (AHI) scored from PSG were compared to the number of wake bouts/hour and actigraphic fragmentation index. Using a PSG-determined AHI of greater than 1 event/hour, the actigraphic measure of wake bouts/hour had a sensitivity and specificity of 14.9% and 98.8%, respectively, and the fragmentation index had a sensitivity and specificity of 12.8% and 97.6%, respectively. Using a PSG-determined arousal index greater than 10 events per hour as the reference standard, the actigraphic measure of wake bouts/hour had a sensitivity and specificity of 78.1% and 52.6% and the fragmentation index had a sensitivity and specificity of 82.2% and 50.9% - both respectively. Based on receiver operator characteristic (ROC) curves, the ability of actigraphic measures to correctly classify a child as having an AHI of greater than 1 event/hour was considered to be poor.
Another study examined the validity of actigraphy for determining sleep and wake in children with sleep disordered breathing with data analyzed over 4 separate activity threshold settings (low, medium, high, auto). (56) The low and auto activity thresholds were found to adequately determine sleep (relative to PSG) but significantly underestimated wake, with sensitivity of 97% and specificity of 39%. The medium- and high-activity thresholds significantly underestimated sleep time (sensitivity of 94% and 90%, respectively) but were not found to be significantly different from the total PSG estimates of wake time (specificity of 59% and 69%). Overall agreement rates between actigraphy and PSG (for both sleep and wake) were 85% to 89%.
A validation study of actigraphy for determining sleep and wake was conducted in 10 preterm infants using videotaped behavioral observations. (57) The study was conducted for a 24-hour period each week while the infants were in the nursery, resulting in a total of 38 studies. Wakefulness was scored as quiet wake with eyes open and "bright", active wake with eyes open and gross body movements, or crying. Sleep included quiet sleep with regular breathing and eyes closed, active sleep with irregular breathing and rapid eye movements, and indeterminate sleep, during which characteristics of both active and quiet sleep were observed. Behavioral sleep-wake scoring was carried out blinded to the knowledge of the actigraphy data. The actigraph, which was synchronized to the video recording, was placed in a custom-designed sleeve bandage and positioned on the infant's leg midway between the knee and ankle. The agreement rate between actigraphic determination of sleep and wake, and behavioral scoring ranged from 66% for the high sensitivity setting at the youngest gestational age (30–33 weeks) to 89% at the low sensitivity setting for infants of 37–40 weeks' gestational age. For the youngest infants, sensitivity and specificity at the low threshold were 88% and 34%, respectively. For infants of 37–40 weeks of gestational age, the sensitivity and specificity were 97% and 32%, respectively. Similar results (97% sensitivity and 24% specificity) were obtained with an epoch-by-epoch comparison of actigraphy and videosomnography in 22 autistic, 11 developmentally delayed, and 25 normally developing preschool children. (58)
Insana et al. compared ankle actigraphic recording and PSG in 22 healthy infants (13 to 15 months of age). (59) Actigraphy was found to underestimate total sleep time by 72 minutes and overestimate wake after sleep onset by 14 minutes. In 55% of the infants, total sleep time was underestimated by equal to or greater than 60 minutes. Sensitivity was calculated for total sleep time (92%), stages 1 and 2 combined (91%), slow wave sleep (96%), and REM sleep (89%). Specificity for identifying wake was 59%, and accuracy was 90%. Overall, actigraphy identified sleep relatively well but was unable to discriminate wake from sleep. Another study compared wrist actigraphy with PSG in 149 healthy school-aged children. (60) Although the sleep period time was not significantly different, actigraphy was found to underestimate total sleep time by 32 minutes (correlation coefficient of 0.47) and overestimate wake after sleep onset by 26 minutes (correlation coefficient of 0.09). The authors concluded that actigraphy is relatively inaccurate for the determination of sleep quality in this population.
The clinical validity of actigraphy depends, to a large extent, on the modality with which it is being compared.
Overall, progress has been made since the 2007 AASM research recommendations in assessing the reliability and validity of different algorithms in comparison with the reference standard. Although actigraphy appears to provide reliable measures of sleep onset and wake time in some patient populations, the clinical utility of actigraphy over the less expensive sleep diary has not been demonstrated. Moreover, evidence indicates that actigraphy does not provide a reliable measure of sleep efficiency in clinical populations. Evidence to date does not indicate that this technology is as beneficial as the established alternatives. Therefore, actigraphy is considered experimental, investigational and unproven.
The recommendations of the AASM are categorized as standards, guidelines, or options. Standards describe a generally accepted patient care strategy, which reflects a high degree of clinical certainty. Guidelines reflect a moderate degree of clinical certainty, while options imply either inconclusive or conflicting evidence or conflicting expert opinion. As noted here, there is only one recommendation considered a standard, and this addresses the technical performance of actigraphic devices (first bullet below). There is also only 1 recommended guideline (second bullet below), and this addresses the small subset of patients with insomnia and restless legs syndrome with specific indications. All of the other recommendations are considered options.
Recommendations of the AASM from 2003 (44):
A 2005 Update for the AASM practice parameters (46) continued to list actigraphy as an option and also suggested areas, such as restless legs syndrome and characterizing circadian rhythm patterns, for further evaluation.
Updated practice parameters in 2007 on the use of actigraphy in the assessment of sleep and sleep disorders (including a separate practice parameter on circadian rhythm sleep disorders) recommended actigraphy as a "standard" only as a method to estimate total sleep time in patients with obstructive sleep apnea syndrome when PSG is not available. (47,48) Other indications changed from option to guideline but failed to reach a recommendation of standard due primarily to the absence of high-quality trials.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
89.17, 89.18, 93.90, 327.23, 780.09, 780.51, 780.53, 780.57
(Obstructive Sleep Apnea references 1-43) (Actigraphy references 45-61)


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Easy cheese appetizers from Toronto's Böhmer restaurant.
Grana Padano Parmesan, finely grated (approximately 2" in diameter and 1/8" thick, or desired size)
300 mL whipping cream (35%)
Goat cheese, crumbled
Desired seasonings (herbs, shallots, salt, pepper)
Parmesan Crisp
Step 1: Fill a silicone baking sheet with small heaps of finely grated Grano Padano Parmesan.
Step 2: Press each heap down with your fingers to flatten it slightly.
Step 3: Bake at 350°F until golden brown and bubbling (approximately 5 minutes, but watch closely). Remove from oven and let cool completely.
Goat Cheese Mousse
Step 1: Whip cream into soft peaks.
Step 2: Fold into crumbled goat cheese. Add desired seasonings to taste.
Step 3: Pipe onto cooled Parmesan crisps and serve.
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DAY 4 REPORT: Tulsa Completes Second Day in Shells
Aug. 5, 2014
TULSA, Okla. - The Tulsa football team practiced for the second time in helmets and shoulder pads on Harwell Field Tuesday, continuing progress toward the Aug. 28 season opener against Tulane at H.A. Chapman Stadium.
The second day in shells brought more hitting and physical workouts. The team worked on red zone situations at the end of the session, producing spirited reactions.
"We got into the red zone and worked on the scoring zone for the offense and where, defensively, you have to really bow up," TU Head Coach Bill Blankenship said. "There were enough wins on both sides to keep us jazzed up. We saw some nice plays. I'm very encouraged."
The play of the day came from junior receiver Conner Floyd. He dove through the air to his right to snag a pass, and held onto it as he rolled to the ground. Blankenship called it an "outstanding" catch. "It really fired everybody up," he said.
Junior running back Tavarreon Dickerson shifted through the defense, breaking long runs. Sophomore quarterback Dane Evans hit sophomore receivers Keevan Lucas and Joshua Atkinson on a pair of nice slant routes, and junior H-back Mandel Dixon Jr. found daylight down the right sideline for a long play.
"TD (Dickerson) is really continuing to show he has the juice to make people miss, and when he does, it's usually house. He has the speed to go the distance," said Blankenship. "Mandel, coming out of spring, was one of the guys on offense that really lit our fire. We think he has the ability to really be a playmaker coming out of the backfield out of his fullback spot. He can catch the ball, he can run - we're hoping to utilize him in a lot of ways."
Despite the standout offensive plays, the defense made its share of stops as well, putting pressure behind the line of scrimmage and breaking up passes downfield.
"Defensively, (Defensive Coordinator) Coach (Brent) Guy is a little frustrated, because he doesn't want to give up any plays. That's the only way you get to be a really good defense - you get really selfish and you don't want to give anything up. But, as long as we're going against ourselves, there's always going to be a little give-and-take. It's OK if maybe the next day the defense wins them all. Then the offense has to get better. But that's what we have to have if we're going to really improve our team."
The Hurricane will practice once more in shells on Wednesday morning at Harwell Field, before putting on full pads for the first time in fall camp on Thursday.
Tulsa football season tickets and 3-game mini-pack plans are on sale now. Go online at TulsaHurricane.com or contact the Tulsa athletic ticket office at 918.631.GoTU. The first month of the season Tulsa will play three home games and one on the road. Tulsa opens the season against American Conference foe Tulane on Thursday, August 28th.
Follow Tulsa Athletics on Twitter at www.Twitter.com/TulsaHurricane and Facebook at www.facebook.com/TulsaHurricane. Follow Tulsa Football on Twitter (www.twitter.com/TUFootball) and Facebook (www.facebook.com/TUFootball).
Fax: 918.631.3666


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Home > Your brain > What does your brain do? > Your senses > Touch and body position >
When you touch something, you detect it using mechanoreceptors just below the surface of your skin. These send the information to your brain. How close can two pinpoint touches be before you sense them as just one touch? It varies over the surface of your body, from 2 millimetres on your fingertips to 40 millimetres on your forearms. The parts of your skin that need to be most sensitive, like your fingertips and your lips, have more receptor cells in them than other, less sensitive areas.