CERTIFICATE OF MEDICAL NECESSITY TO BE ISSUED TO CGHS BENEFICIAREIS BEING PRESCRIBED
Long term Continuous Positive Airway Pressure- CPAP
SUPPORT SYSTEM
(To be filled by the treating physician)
Certification Type - Initial/Revised
1. Patient Name:
2. Age of Patient:
3. Physician Name:
4. Address of Physician:
5. Telephone No. of Physician:
6. (a) Brief history and physical findings:
(b) Co-morbidity (if any):
(c) Whether accompanied by symptoms of
▪ Excessive daytime sleepiness : Yes/No
▪ Snoring : Yes/No
▪ Impaired cognition : Yes/No
▪ Documented cardiovascular disease like
Hypertension, Ischemic heart disease or
Stroke (specify if Yes) : Yes/No
7. Laboratory Data (Specify date against each parameter)
Hematocrit:
ECG:
Blood Sugar (wherever necessary):
Lipid Profile (wherever necessary):
Arterial blood gases 1 2 3
Date
pH
paO2
PaCO2
HCO3a
HCO3s
BE
O2 sat
(Note: The Arterial blood gas values should include those during chronic, stable state
(atleast 3 months after an acute exacerbation) of the disease e.g. in a case of COPD,
the ABG value during acute exacerbation generally demonstrates moderate to severe
hypercapnia which may normalize during stable state and therefore may not be an
indication for long term NIPPV)
X-ray Chest:
Echocardiography (wherever necessary):
Pulmonary function tests:
Thyroid function tests:
Ear, nose & throat examination:
Others (specify):
8. Diagnostic nocturnal polysomnography (NPSG) data: Only whole night polysomnography
(Level-1) including channels for sleep, breathing, pulse oximetry, leg EMG, ECG, snoring will be accepted
for consideration of BI-LEVEL CPAP/BI-LEVEL ventilatory support system
(a) Date of sleep study:
(b) Address of sleep-laboratory/ facility:
(c) Duration of diagnostic NPSG study (in-hours):
(d) Parameters studied during polysomnography
◼ Electro-encephalogram Yes/No
◼ Electro-oculogram Yes/No
◼ Electro-myogram Yes/No
◼ Oro-nasal airflow Yes/No
◼ Chest & abdominal wall effort Yes/No
◼ Body position Yes/No
◼ Snore microphone Yes/No
◼ Electro-cardiogram Yes/No
◼ Oxyhemoglobin saturation Yes/No
(e) Average number of obstructive events per hours of recorded sleep (in case
of standard as well as split NPSG)
(I) Obstructive apnoea*
(ii) Hypopnea**
(iii) Flow limitations***
(iv) RERA
(f) Respiratory Distress Index (RDI)****
9. Date of CPAP titration study:
10. CPAP pressure (in cm H2O) prescribed (to abolish obstructive apnoeas,hypopneas,
RERAs and snoring in all sleep positions and sleep stages):
11. Supplemental oxygen (flow rate of FiO2):
12. Final Diagnosis:
I certify that the medical necessity information is true, accurate and complete to the best of my
knowledge. I have carefully gone through the note for prescribers before filling up this proforma.
Date:
(Full Name, signature & address of Physician)
Note for prescribers (For diagnostic as well as for titration):
Only whole night manually validated Level-1 polysomnography including channels for sleep,
breathing, pulse oximetry, leg EMG, ECG, snoring & CPAP titration will be accepted for
consideration of CPAP/ BiPAP. Screening studies such as Level III, Level IV (Cardio pulmonary
sleep studies) shall not be acceptable. Auto titrated CPAP studies shall also not be acceptable.
* Apneas Absence of airflow on the nasal cannula and < 10% baseline fluctuations on the
thermistor signal, lasting for > 10 s.
*** Flow limitation events: Any series of two or more breaths (lasting > 10s) that had a
flattened or non-sinusoidal appearance on the inspiratory nasal cannula flow signal and ended
abruptly with a return to breaths with sinusoidal shape.
** Hypopneas American Academy of Sleep Medicine (AASM) hypopneas: As proposed by the
AASM Task Force (10), these events include both flow Hypopneas and flow limitation event
associated with 3% desaturation or associated with an AASM arousal.
*** RERA (respiratory effort-related arousal) is defined as an event characterized by increasing
respiratory effort for >10 seconds leading to arousal from sleep but which does not fulfill the
criteria for hypopnoea or apnoea. A RERA is detected with nocturnal esophageal catheter
pressure measurement, which demonstrates a pattern of progressive negative esophageal
pressures terminated in a change in pressure to a less negative pressure level associated with an
arousal.
Upper airway resistance syndrome (UARS): is an abnormal breathing pattern during sleep that
is associated with isolated daytime sleepiness not explained by any other cause, including the
obstructive sleep apnoea/hypopnea syndrome. Essential features include (a) the clinical
complaint of excessive daytime sleepiness; (b) an elevated EEG arousal index (more than ten per
hour of sleep) with arousals related to increased respiratory efforts as measured by
continuous nocturnal monitoring of esophageal pressures; (c) a normal RDI of less than 5 events
per hour of sleep. Supportive features include (a) the clinical complaint of snoring (b) an
increase in snoring intensity prior to EEG arousals and (c) clinical improvement with a short-term
trial of nasal CPAP therapy.
Split-Night Study NPSG: Patients with an RDI of > 40 events per hour during the first 2 hours of a
diagnostic NPSG receive a split-night study NPSG, of which the final portion of the NPSG is used
to titrate CPAP; split-night study may be considered for patients with RDI of 20-40 events
esophageal pressures; (c) a normal RDI of less than 5 events per hour of sleep. Supportive
features Include (a) the clinical complaint of snoring (b) an increase in snoring intensity prior to
EEG arousals and (c) clinical improvement with a short-term trial of nasal CPAP therapy.
Split-Night Study NPSG : Patients with a RDI of > 40 events per hour during the first 2 hours of a
diagnostic NPSG receive a split-night study NPSG, of which the final portion of the NPSG is used
to titrate CPAP; split-night study may be considered for patients with RDI of 20-40 events per
hour, based on clinical observations, such as the occurrence of obstructive respiratory events
with a prolonged duration or in associated with severe oxygen desaturation; a minimum of 3
hours of sleep is preferred to adequately titrate CPAP after this treatment is initiated; split-night
studies require the recording and analysis of the same parameters as a standard diagnostic
NPSG; on occasion, an additional full-night CPAP titration NPSG may be required if the split-
night study did not allow for the abolishment of the vast majority of obstructive respiratory
events or prescribed CPAP treatment does not control clinical symptoms.
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