This document addresses multiple sleep latency testing (MSLT), and other services for the diagnosis of sleep disorders including, but not limited to: "nap" studies; actigraphy, including use of static charge sensitive beds; diagnostic audio recording, with or without pulse oximetry to document sleep apnea; maintenance of wakefulness testing (MWT); topographic brain mapping; and acoustic pharyngometry.

Note: For information related to other technologies utilized in the diagnosis and management of sleep-related disorders, please see:

• SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring;
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea;
• CG-DME-27 Bi-Level Positive Airway Pressure (BPAP) Respiratory Assist Devices;
• CG-DME-32 Continuous Positive Airway Pressure (CPAP) and Auto-titrating Positive Airway Pressure (APAP) Devices;
• CG-MED-01 Polysomnography and Home Portable Monitors.

Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT)

Medically Necessary: 

Multiple sleep latency testing (MSLT) is considered medically necessary for the evaluation of the following two conditions:

• Narcolepsy;  or
• Suspected idiopathic hypersomnia. 

Not Medically Necessary:

MSLT is considered not medically necessary in the following four situations:

• When performed for routine diagnosis of obstructive sleep apnea; or
• For routine follow-up after treatment of sleep related disorders; or
• For evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia), including, but not limited to, insomnia, circadian rhythm disorders, and Shift Work Sleep Disorder (SWSD); or
• Portable MSLT performed in the home setting. 

Investigational and Not Medically Necessary:

Maintenance of wakefulness testing (MWT) is considered investigational and not medically necessary for the evaluation, diagnosis or assessment of response to therapy for sleep disorders.

Other Services

Investigational and Not Medically Necessary:

"Nap" studies are considered investigational and not medically necessary either for screening purposes or as an alternative to polysomnography for the diagnosis of obstructive sleep apnea or narcolepsy.

 The following diagnostic tests are considered investigational and not medically necessary:

1. Diagnostic audio recording, with or without pulse oximetry, to document sleep apnea;
2. Topographic brain mapping;
3. Acoustic pharyngometry (Eccovision^™ Acoustic Pharyngometer^®);
4. Actigraphy or static charge sensitive beds.

The available evidence in the medical literature is sufficient to recommend the use of Multiple Sleep Latency Testing (MSLT) with polysomnography (PSG) for the diagnosis of narcolepsy or suspected idiopathic hypersomnia. According to the AASM Practice Parameters for Clinical Use of the Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT), MSLT is indicated as part of the evaluation of individuals with suspected narcolepsy to confirm the diagnosis, because the co-occurrence of OSA syndrome and narcolepsy is well documented in the published literature.  This AASM paper states further that, "MSLT may be indicated as part of the evaluation of patients with suspected idiopathic hypersomnia to help differentiate idiopathic hypersomnia from narcolepsy" (Littner, 2005).  The 2009 updated AASM Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults made the following comments about MSLT testing:

MSLT is not routinely indicated in the initial evaluation and diagnosis of OSA or in an assessment of change following treatment with nasal CPAP. However, if excessive sleepiness continues despite optimal treatment, the patient may require an evaluation for possible narcolepsy, including MSLT (Guideline).  (Epstein, 2009)

While there is sufficient evidence to recommend that PSG be done prior to an MSLT, there is not adequate information regarding how soon after PSG the MSLT may be done.  For the sake of convenience, it is common practice for the MSLT to be done immediately following the PSG and if not possible, the MSLT should be done within a reasonable time afterward.  However, the use of MSLT as the sole diagnostic tool or performed routinely, in addition to PSG for the diagnosis of sleep apnea or for sleepiness associated with conditions other than narcolepsy or idiopathic hypersomnia, is not supported by evidence in the medical literature.

The utility of Maintenance of Wakefulness Testing (MWT), in terms of improved health outcomes, has not been established. The 2005 AASM Practice Parameters (Littner, 2005) note there are no standard or generally accepted guidelines for the performance of an MWT, and several variations in protocol exist, based on differences in definitions of sleep onset, trial duration and the need for previous night PSG.  Normative data, sensitivity and specificity data in various tested 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 individual's clinical response to therapy in these disorders, or would influence clinical decision-making, thereby improving 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" (Littner, 2005). 

The evidence in the medical literature does not support the use of single nap studies.  This type of study has not been proven to meet the standards and capabilities of sleep studies conducted in a formal sleep laboratory.  Wide deviations in the conditions and data collection methods available in these types of studies cause too much variability in the result quality for proper sleep assessment.  Additionally, nap sleep is not physiologically the same as nighttime sleep, and does not adequately reflect the range of sleep phases required for proper diagnosis, so results are not accurate when compared to full PSG. 

While the use of actigraphy has been demonstrated to be useful in the detection of sleep problems in "healthy" individuals, potential benefits for individuals with suspected sleep disorders have not been shown.  The current body of evidence supporting the use of actigraphy for individuals with sleep disorders is insufficient to allow adequate conclusions regarding efficacy.  The 2009 updated AASM document made the following statement: "Actigraphy alone is not indicated for the routine diagnosis of OSA but may be a useful adjunct to PMs when determining the rest-activity pattern during the testing period (Option)" (Epstein, 2009).

The potential benefits of diagnostic audio recording, used alone or in conjunction with pulse oximetry, has not been demonstrated to provide clinical benefits equivalent to the currently accepted standard of care, PSG.  While such methods do potentially identify occurrences of sleep apnea, other aspects of physiological functioning are not recorded simultaneously, thus providing an incomplete clinical picture and allowing the possibility of misdiagnosis.

The Eccovision^™ Acoustic Reflection Pharyngometer^® (Hood Laboratories, Pembroke, MA) is another noninvasive testing device intended to measure the upper respiratory airway by means of acoustic reflection.  Some studies have suggested a correlation between pharyngeal cross-sectional areas measured using acoustic pharyngometry and the presence of OSA; also that sites of airway narrowing may potentially be identified.  However, at the present time, the utility of acoustic pharyngometry measurement in the clinical setting of OSA has not been demonstrated, in terms of how this testing will impact treatment planning and clinical outcomes.

Topographic brain mapping has been briefly described in the evaluation and diagnosis of OSA.  However, the evidence is limited to small case series studies that do not allow full evaluation of this technology.  At this time, the level of evidence supporting topographic brain mapping is insufficient to make any recommendations.  The updated 2009 AASM document does not address MWT, nap studies, audio recording, SNAP testing, acoustic pharyngometry or topographic brain mapping (Epstein, 2009).

Description of Sleep Disorders

Sleep disorders are some of the most common medical problems in the United States and have a significant impact on quality of life, productivity, and health.  There are many different types of sleep-related disorders, including obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), insomnia, narcolepsy, nocturnal movement disorders, such as Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD), unexplained excessive daytime sleepiness, and arousal disorders (parasomnias).  Most, if not all, of these sleep-related disorders are treatable if diagnosed properly.

Sleep disorder studies, including PSG and MSLT, are used to determine or confirm a diagnosis related to sleep disturbances.  These tests monitor various bodily functions including heart and respiratory rate, body position and movement, to gain an understanding of the conditions under which sleep disturbances occur.  OSA represents a very large portion and is the focus of this document.  Another type of sleep disturbance is simply known as "apnea" or "central apnea."  This condition, caused by problems in the central nervous system, is unrelated to OSA and is not addressed in this document.

An MSLT consists of four or five nap opportunities to determine both severity of sleepiness and presence of sleep onset rapid eye movement (REM) periods.  The presence of sleep onset REM (also known as SOREM) in a nap, as well as the number of naps in which sleep onset REM is detected, are recorded as well.  For correct interpretation, the MSLT must be performed following an all-night PSG.  The individual is given the opportunity to nap at scheduled intervals for 20 minutes.  Sleep is monitored and the sleep onset (if sleep occurs) is determined by the first EEG appearance of any stage of sleep, including stage 1 sleep.  The sleep latency is the time interval from the onset of the nap to the onset of sleep on the monitored EEG.  The Mean Sleep Latency is then determined by calculating the mean of the sleep latencies of the nap opportunities.

An individual receiving an MSLT should first undergo a PSG to determine if an MSLT is needed.  The MSLT may be performed immediately following or at some time shortly after a PSG study.  During an MSLT, the individual has various sensors attached to their body, and they are encouraged to fall asleep.  Once asleep, the individual is aroused several times and then allowed to fall back to sleep.  The time it takes for the individual to fall back to sleep is used as an indicator of various sleep disorders.  Depending upon the results of the test, a diagnosis may be determined.

Many other portable tests have been proposed as alternatives to laboratory-based PSG for the diagnosis and follow-up of sleep disorders.  These tests include, but are not limited, to: "nap studies," actigraphy, diagnostic audio-taping, MWT, topographic brain mapping, and acoustic pharyngometry. However, none of these portable tests are currently considered to provide diagnostic information that is superior to established Type III portable test devices.

Acoustic Reflection Pharyngometry^® (Eccovision^™):  This is a noninvasive device that uses acoustic signal processing technology to provide a graphical representation of airway patency.  The technique is based on the analysis of sound waves that are launched from a loudspeaker and travel along a wave tube into the subject's airways where they are reflected.  Measurement of differences in the reflected wave signals enables a graphic representation of the variations in pharyngeal cross-sectional area at several anatomic levels.

Actigraphy:  This is a method used to study sleep-wake patterns and circadian rhythms by assessing the subject's movement over a period of time.  Measurements usually involve the detection of wrist movements.

Airflow and Respiratory Effort in conjunction with Oxygen Saturation:  These terms are translated into the standard measures of apneic-hypopneic index (AHI) or respiratory disturbance index (RDI).  Oxygen saturation measures the significance of respiratory events.  Other types of sleep studies are generally referred to as either portable or home sleep studies and are further categorized as described above.

Apnea:  A transient period where breathing ceases.

Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI):  A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep.  For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use.  An AHI/RDI greater than 30 is consistent with severe OSA.  In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value.  These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.

Continuous Positive Airway Pressure (CPAP):  This is a noninvasive treatment for OSA that involves delivery of pressurized air during sleep through a device that snugly covers the nose.  The appropriate setting for standard CPAP treatment is determined during a titration sleep study.

Epworth Sleepiness Scale (ESS):  A standardized measure of the degree of sleepiness.

Excessive Daytime Sleepiness:  This refers to a condition where a person feels very drowsy during the day, even after getting adequate night time rest, and has a tendency to fall asleep or requires extra effort to avoid sleeping in inappropriate situations, such as at work or driving.  This condition is also defined as a score greater than or equal to 10 on the Epworth Sleepiness Scale.

Home/Portable Sleep Study (may also be known as NightWatch^™ System, AutoSet^® Recorder, Morpheus^™ System):  A diagnostic test proposed for home use which may be self-administered or attended by a technician.  The machine is returned to the doctor the following morning for data analysis.

Hypopnea:  Breathing that is more shallow, and/or slower, than normal.

Maintenance of Wakefulness Test (MWT):  This is a laboratory-based test intended to measure the physiological sleep tendency under standardized conditions in the absence of external alerting factors.  The MWT measures the ability to stay awake for a defined period of time, (generally a 40 minute protocol is used), with the first epoch of sleep as the definition of sleep onset.

Multiple Sleep Latency Test (MSLT):  This is a test used in conjunction with PSG to determine the presence and severity of sleepiness.  During this test, the subject is given the opportunity to take naps at specified time intervals.  The test consists of four or five nap opportunities at two hour intervals.  Each nap opportunity is 20 minutes in duration.  Individuals with excessive daytime sleepiness may fall asleep almost immediately, while those without excessive sleepiness may not fall asleep at all.  Severe sleepiness is usually associated with an MSLT mean sleep latency of less than 5 minutes.  The presence of sleep onset rapid eye movement (REM) and the number of naps in which sleep REM occurs are also determined.

Nap Study:  This term refers to a shorter daytime version of a PSG sleep study.

Narcolepsy:  This refers to a neurological condition, where individuals experience profound daytime sleepiness, which may also include sudden, periodic, and transient loss of muscle tone associated with extreme emotions, such as laughter or anger (cataplexy).

Obstructive Sleep Apnea (OSA):  This is a form of sleep disturbance, which occurs as the result of a physical occlusion of the upper airway during sleep, which interferes with normal breathing.  The occlusion is usually in the back of the tongue and/or flabby tissue in the upper airway.  This condition is associated with frequent awakening and often with daytime sleepiness.

According to the American Academy of Sleep Medicine (AASM), updated definitions of OSA severity are provided as follows:
Mild OSA: AHI of 5-15 Involuntary sleepiness during activities that require little attention, such as watching TV or reading;
Moderate OSA: AHI of 15-30 Involuntary sleepiness during activities that require some attention, such as meetings or presentations;
Severe OSA: AHI of more than 30 Involuntary sleepiness during activities that require more active attention, such as talking or driving (AASM, 2008).
Shift Work Sleep Disorder (SWSD):  A sleep disorder that is related to unusual or constantly changing work schedules and results in symptoms of insomnia or excessive sleepiness.
Sleep Disorder:  A disruptive pattern of sleep that may include difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep.

Upper Airway:  The area of the upper respiratory system including the nose, mouth and throat.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Multiple Sleep Latency (MSLT) and Maintenance of Wakefulness (MWT) Testing
When services are Medically Necessary (for MSLT):

When services are Not Medically Necessary (for MSLT):
For the above procedure code specified as MSLT, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position statement section as not medically necessary.

When services are Investigational and Not Medically Necessary (for MWT): 

Other services
When services are also Investigational and Not Medically Necessary: 

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

Peer Reviewed Publications:

1. Aldrich MS, Chervin RD, Malow BA. Value of the multiple sleep latency test (MSLT) for the diagnosis of narcolepsy. Sleep. 1997; 20(8):620-629.
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5. Bonnet MH. The MSLT and MWT should not be used for the assessment of workplace safety. J Clin Sleep Med. 2006; 2(2):128-131. 
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16. Netzer NC, Stoohs RA, Netzer CM, et al. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.  Ann Intern Med. 1999; 131(7):485-491.
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21. Watanabe T, Kumano-Go T, Suganuma N, et al.  The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome.  Sleep Res Online. 2000; 3(4):169-172.
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Government Agency, Medical Society, and Other Authoritative Publications: 

1. Agency for Healthcare Policy and Research. Systematic review of the literature regarding the diagnosis of sleep apnea. Evidence Report/Technology Assessment No. 1. AHCPR Publication No. 99-E002. Bethesda, MD: AHCPR, December 1998.
2. American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002; 109(4):704-712.  Available at:  http://aappolicy.aappublications.org/cgi/reprint/pediatrics;109/4/704.pdf.  Accessed on September 5, 2011.
3. American Academy of Sleep Medicine. Practice parameters for role of actigraphy in the study of sleep and circadian rhythms: An update for 2002. Sleep. 2003; 26(3):337-347.
4. American Academy of Sleep Medicine. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults.  Sleep. 2003; 26(7):907-913.
5. American Academy of Sleep Medicine. Standards of Practice Committee:  Practice parameters for clinical use of the multiple sleep latency tests and the maintenance of wakefulness test (sleepiness; hypersomnia; daytime wakefulness).  Sleep. 2005; 28(1):113-121.
6. American Academy of Sleep Medicine (AASM). Obstructive Sleep Apnea. 2008. Available at: http://www.aasmnet.org/Resources/FactSheets/SleepApnea.pdf.  Accessed on September 2, 2011.
7. American Academy of Sleep Medicine (AASM). Standards for Accreditation of Out of Center Sleep Testing (OCST) in Adult Patients. 2011.  Available at:  http://www.aasmnet.org/ocststandards.aspx.  Accessed on September 3, 2011.
8. American Sleep Disorders Association. A Position Paper: Guidelines for the clinical use of the Multiple Sleep Latency Test. Sleep. 1992; 15(3):268-276. 
9. American Sleep Disorders Association, Standards of Practice Committee. Practice parameter for the use of portable recording of the assessment of obstructive sleep apnea. Sleep. 1994; 17(4):372-377.
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11. Blue Cross and Blue Shield Assoc. Technology Evaluation Center (TEC) assessments. Portable sleep studies for the diagnosis of obstructive sleep apnea syndrome. 1996; 11(2).
12. Canadian Agency for Drugs and Technologies in Health (CADTH).  Portable Monitoring Devices for Diagnosis of Obstructive Sleep Apnea at Home: Review of Accuracy, Cost-Effectiveness, Guidelines, and Coverage in Canada.  December 2009.  Available at:  http://www.cadth.ca/media/pdf/M0002_Portable_Monitoring_Devices_Obstructive_Sleep_Apnea_L3_e.pdf.  Accessed on September 5, 2011.
13. Centers for Medicare and Medicaid Services. National Coverage Determination for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA). NCD #240.4. Effective March 13, 2008. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&DocID=240.4&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&.  Accessed on September 5, 2011.
14. Centers for Medicare and Medicaid Services. National Coverage Determination for Sleep Testing for Obstructive Sleep Apnea. NCD #240.4.1. Effective March 3, 2009.  Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&ncd_id=240.4&ncd_version=3&basket=ncd%25253A240%25252E4%25253A3%25253AContinuous+Positive+Airway+Pressure+%252528CPAP%252529+Therapy+For+Obstructive+Sleep+Apnea+%252528OSA%252529&bc=gAAAAAgAAAAA&.  Accessed on September 5, 2011 .
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16. Chesson AL Jr, Berry RB, Pack A. Practice parameters for the use of portable monitoring devices in the  investigation of suspected obstructive sleep apnea in adults. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians.  Sleep. 2003, 26(7):907-913.
17. Collop NA, Anderson WM, Boehlecke B, et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007; 3(7):737-747. Available at: http://www.aasmnet.org/jcsm/AcceptedPapers/PMProof.pdf. Accessed on September 5, 2011.
18. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5(3):263-276.  Available at: http://www.aasmnet.org/Resources/ClinicalGuidelines/OSA_Adults.pdf.  Accessed on September 5, 2011.
19. Flemons WW, Littner MR, Rowley JA, et al.  Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest. 2003; 124(4):1543-1579.
20. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Westchester, IL: American Academy of Sleep Medicine; 2007.
21. Littner MR, Kushida C, Wise M, et al. American Academy of Sleep Medicine Report: Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test.  Standards of Practice Committee of the American Academy of Sleep Medicine.  2005 update intended to replace the 1992 Position Paper of the American Sleep Disorders Association on the Clinical Use of the Multiple Sleep Latency Test.  Sleep. 2005; 28(1):113-121.
22. Morgenthaler T, Alessi C, Friedman L, et al. Standards of Practice Committee, American Academy of Sleep Medicine. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007; 30(4):519-529.
23. Morgenthaler TI, Aurora RN, Brown T, et al. Standards of Practice Committee of the American Academy of Sleep Medicine (AASM).  Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine Report. Sleep. 2008; 31(1):141-147. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2225554/pdf/aasm.31.1.141.pdf.  Accessed on September 2, 2011.
24. Schechter MS. American Academy of Pediatrics technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002; 109(4):e69.
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26. Thurnheer R, Bloch KE, Laube I et al; Swiss Respiratory Polygraphy Registry. Respiratory polygraphy in sleep apnoea diagnosis. Report of the Swiss respiratory polygraphy registry and systematic review of the literature. Swiss Med Wkly. 2007; 137(5-6):97-102.
27. Trikalinos TA, Ip S, Raman G, et al. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. AHRQ Technology Assessment Program. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD; August 8, 2007. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id48TA.pdf.  Accessed on September 5, 2011.
28. U.S. Food and Drug Administration 510(k) Premarket Notification Database.  Eccovision Acoustic Diagnostic Imaging Acoustic Pharyngometer Summary of Safety and Effectiveness.  No. K011329.  Rockville, MD: FDA. July 26, 2002.  Available at:   http://www.accessdata.fda.gov/cdrh_docs/pdf/K011329.pdf.  Accessed on September 5, 2011.

1. Journal of the American Medical Association.  Patient Page. Breathing Problems during Sleep.  JAMA. 2001;  285(22):2936.  Available at:  http://jama.ama-assn.org/cgi/reprint/285/22/2936?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=Patient+page%3A++Breathing+problems+during+sleep&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.  Accessed on September 5, 2011.
2. National Heart, Lung and Blood Institute (NHLBI). Information about Sleep Disorders.  Available at: http://www.nhlbi.nih.gov/health/dci/Browse/Sleep.html.  Accessed on September 5, 2011.

Apnea/Hypopnea Index (AHI)
Apnea Risk Evaluation System (ARES^™)
Electrosleep Therapy
Obstructive Sleep Apnea (OSA)
SleepStrip^™
Topographic EEG Mapping 

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.