MEDICAL POLICY 7.01.554
Surgical Treatment of Snoring and Obstructive Sleep
Apnea Syndrome
Effective Date: June 1, 2018
Last Revised: June 1, 2018
Replaces: N/A
RELATED MEDICAL POLICIES:
11.01.524 Site of Service: Select Surgical Procedures
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | CODING | RELATED INFORMATION
EVIDENCE REVIEW | REFERENCES | HISTORY
Clicking this icon returns you to the hyperlinks menu above.
Introduction
Obstructive sleep apnea (OSA) is a blockage in the upper part of the airway. The blockage is
usually from throat muscles collapsing, the tongue falling into the airway, or large tonsils or
adenoids getting in the way of airflow. Positive airway pressure (PAP) devices are very effective
in treating sleep apnea. A PAP device works by increasing air pressure in the throat to prevent it
from collapsing as a person breathes. When a PAP device doesnt work or there are certain other
medical situations, surgery can be a way to treat sleep apnea. There are a number of different
types of surgery, but they generally treat OSA by removing extra tissue in the throat to widen
the airway. There are also a number of other surgeries or devices that are still being studied.
They are not covered because there is not enough medical evidence to show they work. This
policy discusses when medically necessary surgeries for OSA may be approved.
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
Policy Coverage Criteria
https://www.lifewisewa.com/medicalpolicies/11.01.524.pdf
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Site of service is defined as the location where the surgical procedure is performed, such as an
off campus-outpatient hospital or medical center, an on campus-outpatient hospital or medical
center, an ambulatory surgical center, or an inpatient hospital or medical center.
Site of Service for
Elective Surgical
Procedures
Medical Necessity
Medically necessary sites
of service:
Off campus-outpatient
hospital/medical center
On campus-outpatient
hospital/medical center
Ambulatory Surgical
Center
Certain elective surgical procedures will be covered in the most
appropriate, safe, and cost effective site. These are the
preferred medically necessary sites of service for certain
elective surgical procedures.
Inpatient hospital/medical
center
Certain elective surgical procedures will be covered in the most
appropriate, safe, and cost-effective site. This site is
considered medically necessary only when the patient has a
clinical condition which puts him or her at increased risk for
complications including any of the following (this list may not
be all inclusive):
Anesthesia Risk
o ASA classification III or higher (see definition)
o Personal history of complication of anesthesia
o Documentation of alcohol dependence or history of
cocaine use
o Prolonged surgery (>3 hours)
Cardiovascular Risk
o Uncompensated chronic heart failure (NYHA class III or IV)
o Recent history of myocardial infarction (MI) (
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Site of Service for
Elective Surgical
Procedures
Medical Necessity
Liver Risk
o Advance liver disease (MELD Score > 8)**
Pulmonary Risk
o Chronic obstructive pulmonary disease (COPD) (FEV1
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Treatment Medical Necessity have not responded to or do not tolerate nasal continuous
positive airway pressure (CPAP).
Note: Clinically significant OSA is defined in the Related Information section.
Hyoid suspension, surgical
modification of the tongue,
and/or maxillofacial
surgery
Hyoid suspension, surgical modification of the tongue, and/or
maxillofacial surgery, including mandibular-maxillary
advancement (MMA), may be considered medically necessary
in appropriately selected adult patients with clinically
significant OSA and objective documentation of
hypopharyngeal obstruction who have not responded to or do
not tolerate CPAP.
Note: Clinically significant OSA is defined in the Related Information section.
Adenotonsillectomy Adenotonsillectomy may be considered medically necessary in
pediatric patients with clinically significant OSA and
hypertrophic tonsils.
Note: Clinically significant OSA is defined in the Related Information section.
All interventions in the
absence of documented
OSA
All interventions, including LAUP (laser-assisted
uvulopalatoplasty), radiofrequency volumetric tissue
reduction of the palate, or palatal stiffening procedures are
considered not medically necessary for the treatment of
snoring in the absence of documented OSA; snoring alone is
not considered a medical condition.
Treatment Investigational Implantable hypoglossal
nerve stimulators
Implantable hypoglossal nerve stimulators are investigational
for all indications, including but not limited to the treatment
of obstructive sleep apnea (OSA).
Minimally-invasive surgical
procedures
The following minimally-invasive surgical procedures are
investigational for the sole or adjunctive treatment of OSA or
upper airway resistance syndrome (UARS):
Radiofrequency volumetric tissue reduction of the tongue (eg,
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Treatment Investigational Somnoplasty), with or without radiofrequency reduction of the
palatal tissues
Laser-assisted uvulopalatoplasty (LAUP) or radiofrequency
volumetric tissue reduction of the palatal tissues
Palatal stiffening procedures including, but not limited to,
cautery-assisted palatal stiffening operation (CAPSO), injection
of a sclerosing agent, and the implantation of palatal implants
(eg, Pillar Procedure)
Tongue base suspension (eg, Airvance System, formerly the
Repose Tongue and Hyoid Suspension System, Encore
system)
All other minimally-invasive surgical procedures not described
above
Coding
Code Description
CPT 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including
connection to pulse generator (List separately in addition to code for primary
procedure)
0467T Revision or replacement of chest wall respiratory sensor electrode or electrode array,
including connection to existing pulse generator
21199 Osteotomy, mandible, segmental; with genioglossus advancement
41512 Tongue base suspension, permanent suture technique
41530 Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session
42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)
42299 Unlisted procedure, palate, uvula
42950 Pharyngoplasty (plastic or reconstructive operation on pharynx)
64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode
array and pulse generator
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Code Description
HCPCS
S2080 Laser-assisted uvulopalatoplasty (LAUP)
Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
Related Information
Continuous positive airway pressure is the preferred first-line treatment for most patients with
OSA. A smaller number of patients may use oral appliances as a first-line treatment (see Related
Policies).
The Apnea/Hypopnea Index is the total number events (apnea or hypopnea) per hour of
recorded sleep. The Respiratory Disturbance Index is the total number events (apnea or
hypopnea) per hour of recording time. An obstructive apnea is defined as at least a 10-second
cessation of respiration associated with ongoing ventilatory effort. Hypopnea is defined as an
abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in
thoracoabdominal movement or airflow compared with baseline, and with at least a 4% oxygen
desaturation.
Definition of Terms
American Society of Anesthesiologists (ASA) Score:
ASA 1 A normal healthy patient.
ASA 2 A patient with mild systemic disease.
ASA 3 A patient with severe systemic disease.
ASA 4 A patient with severe systemic disease that is a constant threat to life.
ASA 5 A moribund patient who is not expected to survive
New York Heart Association (NYHA) Classification:
Class I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath
when walking, climbing stairs etc.
Class II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during
Page | 7 of 18
ordinary activity.
Class III Marked limitation in activity due to symptoms, even during less-than-ordinary
activity, eg, walking short distances (20100 m).Comfortable only at rest.
Class IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound
patients
Adults
The diagnosis of OSA in adults is confirmed by a sleep study result showing:
The apneic/hypopneic index (AHI) is greater than or equal to 15 events per hour, including a
minimum of 30 events documented per sleep study; or
The AHI is greater than or equal to 5 events per hour and less than 15 events per hour,
including a minimum of 10 events documented per sleep study, AND documentation of:
o History of stroke; or
o Hypertension (systolic blood pressure greater than 140 mm Hg and/or diastolic blood
pressure greater than 90 mm Hg); or
o Ischemic heart disease; or
o Symptoms of impaired cognition, mood disorders, or insomnia; or
o Excessive daytime sleepiness (documented by either Epworth greater than 10 or MSLT
less than 6); or
o Greater than 20 episodes of desaturation (ie, oxygen saturation of less than 85%) during
a full night sleep study, or any 1 episode of oxygen desaturation (ie, oxygen saturation of
less than 70%); or
o Obesity (BMI greater than 35)
OSA severity is defined as:
Mild for AHI 5/hr and < 15/hr.
Moderate for AHI 15/hr and < 30/hr.
Severe for AHI 30/hr.
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The AHI is the total number events (apnea or hypopnea) per hour of recorded sleep. An
obstructive apnea is defined as at least a 10-second cessation of respiration associated with
ongoing ventilatory effort. Hypopnea is defined as an abnormal respiratory event lasting at least
10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as
compared to baseline, and with at least a 4% oxygen desaturation.
Children
The presentation of OSA in pediatric patients may differ from that of adults.
The diagnosis of obstructive sleep apnea in children is established by a sleep study result
showing an apneic/hypopneic index (AHI) greater than 1.5. (An AHI of 1.5 is considered severe in
children.)
Upper airway resistance syndrome (UARS)
Clinically significant upper airway resistance syndrome (UARS) is defined as greater than 10 EEG
arousals per hour. The presence of abnormally negative intrathoracic pressures (ie, more
negative than 10 cm) in conjunction with the EEG arousals supports the diagnosis. The
measurement of intrathoracic pressures requires the use of an esophageal manometer as an
adjunct to a polysomnogram. Objective evidence of hypopharyngeal obstruction is documented
by either fiberoptic endoscopy or cephalometric radiographs.
Evidence Review
Description
Obstructive sleep apnea (OSA) syndrome is characterized by repetitive episodes of upper airway
obstruction due to the collapse of the upper airway during sleep. For patients who have failed
conservative therapy, established surgical approaches may be indicated. This policy addresses
minimally invasive surgical procedures for the treatment of OSA. They include laser-assisted
uvuloplasty, tongue base suspension, radiofrequency volumetric reduction of palatal tissues and
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base of tongue, palatal stiffening procedures, and hypoglossal nerve stimulation. This policy
does not address conventional surgical procedures such as uvulopalatopharyngoplasty, hyoid
suspension, surgical modification of the tongue, maxillofacial surgery, or adenotonsillectomy.
Background
Obstructive sleep apnea (OSA) is characterized by repetitive episodes of upper airway
obstruction due to the collapse and obstruction of the upper airway during sleep. In patients
with OSA, the normal pharyngeal narrowing may be accentuated by anatomic factors, such as a
short, fat bull neck, elongated palate and uvula, and large tonsillar pillars with redundant
lateral pharyngeal wall mucosa. In addition, OSA is associated with obesity. OSA may also be
associated with a variety of craniofacial abnormalities, including micrognathia, retrognathia, or
maxillary hypoplasia. Obstruction anywhere along the upper airway can result in apnea.
The hallmark symptom of OSA is excessive daytime sleepiness, and the typical clinical sign of
OSA is snoring, which can abruptly cease and be followed by gasping associated with a brief
arousal from sleep. The snoring resumes when the patient falls back to sleep, and the cycle of
snoring/apnea/arousal may be repeated as frequently as every minute throughout the night.
Sleep fragmentation associated with the 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, ie, 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 hypoxia, alveolar hypoventilation, hypercapnia, and acidosis. This in turn can cause
systemic hypertension, cardiac arrhythmias, 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 overwhelming sleepiness.
The evidence on hypoglossal nerve stimulation for the treatment of OSA includes case series
and one prospective cohort of about 100 patients followed for 3 years. For patients who had
failed conservative therapy and met the inclusion criteria for AHI, BMI, and favorable pattern of
palatal collapse, about two-thirds met the study definition of success. Results observed at the
12-month follow-up were maintained at 3 years. However, the comparative efficacy of this
procedure relative to established OSA treatment options is uncertain. Additional study
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comparing hypoglossal nerve stimulation to established surgical procedures is needed to permit
conclusions on the effect of this treatment on health outcomes.
Summary of Evidence
For individuals who have obstructive sleep apnea (OSA) who receive laser-assisted
uvulopalatoplasty, tongue base suspension, radiofrequency volumetric reduction of palatal
tissues and base of tongue, palatal stiffening procedures, or hypoglossal nerve stimulation, the
evidence includes case series, cohort studies, and randomized controlled trials (RCTs). Relevant
outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.
The evidence on nearly all of the minimally invasive surgical procedures reviewed herein has
shown limited efficacy in patients with mild-to-moderate OSA and has not improved Apnea-
Hypopnea Index (AHI) or excessive daytime sleepiness in adults with moderate-to-severe OSA.
Hypoglossal nerve stimulation has shown improved outcomes in single arm studies when used
in a very select group of patients. In the largest study to date, two-thirds of patients who met
inclusion criteria for AHI, body mass index, and favorable pattern of palatal collapse met the
study definition of success. However, the role of nerve stimulation among the surgical
procedures for OSA treatment is uncertain. RCTs comparing hypoglossal nerve stimulation to
conventional surgical procedures are needed to evaluate benefits and harms. The evidence is
insufficient to determine the effects of the technology on health outcomes.
Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed in Table 1.
Table 1. Summary of Key Trials
NCT No. Trial Name Planned
Enrollment
Completion
Date
Ongoing
NCT02907398a Adherence and Outcome of Upper Airway
Stimulation (UAS) for OSA International Registry
2500 Sep 2019
https://www.clinicaltrials.gov/ct2/show/NCT02907398?term=NCT02907398&rank=1
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NCT No. Trial Name Planned
Enrollment
Completion
Date
NCT02263859a ImThera Medical Targeted Hypoglossal
Neurostimulation Study #3 (THN3)
141 May 2021
NCT02413970 Inspire Upper Airway Stimulation System (UAS):
Post-Approval Study Protocol Number 2014-001
127 Dec 2021
Unpublished
NCT01446601a Pivotal Study of the Apnex Medical Hypoglossal
Nerve Stimulation (HGNS) System to Treat
Obstructive Sleep Apnea
132 Aug 2013
(terminated)
NCT02293746a Inspire Upper Airway Stimulation (UAS) System
German Post-Market Study: CE Certificate
Number 562872
60 Jan 2017
(completed)
NCT: national clinical trial. a Denotes industry-sponsored or cosponsored trial.
Practice Guidelines and Position Statements
American Academy of Sleep Medicine (AASM)
The American Academy of Sleep Medicine (AASM) published practice parameters for surgical
modifications of the upper airway for obstructive sleep apnea (OSA) in 2010.23 AASM practice
parameters were based on a systematic review of the evidence that found that the published
literature was comprised primarily of case series, with few controlled trials and varying
approaches to preoperative evaluation and postoperative follow-up.24 Using the change in
Apnea-Hypopnea Index (AHI) as the primary measure of efficacy, substantial and consistent
reductions were observed following mandibular-maxillary advancement (MMA), and adverse
events were uncommonly reported. Outcomes following pharyngeal surgeries were less
consistent, and adverse events were more commonly reported. The review found that outcomes
of studies with newer pharyngeal techniques and multilevel procedures, performed in small
numbers of patients, appear promising. The practice parameters noted the lack of rigorous data
evaluating surgical modifications of the upper airway, resulting in a recommendation of option
(uncertain clinical use) for MMA, uvulopalatopharyngoplasty (UPPP) as a sole procedure, or
multilevel or stepwise surgery if patients failed UPPP as a sole treatment. Use of radiofrequency
ablation was recommended as an option for patients with mild-to-moderate OSA who cannot
tolerate or are unwilling to adhere to continuous positive airway pressure (CPAP), or in whom
https://www.clinicaltrials.gov/ct2/show/NCT02263859?term=NCT02263859&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02413970?term=NCT02413970&rank=1https://www.clinicaltrials.gov/ct2/show/NCT01446601?term=NCT01446601&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02293746?term=NCT02293746&rank=1
Page | 12 of 18
oral appliances have been found ineffective or undesirable. Palatal implants were recommended
as an option for patients with mild OSA who failed medical therapy. Laser-assisted
uvulopalatoplasty was not recommended as a routine treatment for OSA (standard). The
practice parameters recommended as standard the need to determine the presence and
severity of OSA before initiating surgical therapy, discussion of success rates, complications, and
alternative treatments with the patient, and a postoperative follow-up evaluation, which includes
a clinical evaluation and an objective measure of the presence and severity of sleep-disordered
breathing and oxygen saturation. However, little guidance was available in the medical literature
to recommend any particular monitoring strategy. The optimal interval and duration of this
follow-up were also not clear from the available literature.
The American Academy of Pediatrics (AAP)
The AAP published a 2012 clinical practice guideline on the diagnosis and management of
childhood OSA.25 AAP recommends that if a child has OSA, a clinical examination consistent with
adenotonsillar hypertrophy, and does not have a contraindication to surgery, the clinician
should recommend adenotonsillectomy as the first line of treatment. AAP recommends that
patients should be referred for CPAP management if symptoms/signs or objective evidence of
OAS persists after adenotonsillectomy or if adenotonsillectomy is not performed. Weight loss
should be recommended in addition to other therapy if a child/adolescent with OSA is
overweight or obese
The American Academy of Otolaryngology - Head and Neck Surgery
(AAO-HNS)
The 2016 American Academy of Otolaryngology-Head and Neck Surgery position statement on
hypoglossal nerve stimulation for treatment of obstructive sleep apnea (OSA)26 states: upper
airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep
apnea syndrome to be an effective second-line treatment of moderate to severe obstructive
sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure
therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate
polysomnographic, age, BMI and objective upper airway evaluation measures are required for
proper patient selection.
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The American Academy of OtolaryngologyHead and Neck Surgery (AAO-HNS) has a 2014
revised policy statement on surgical management of OSA.26 Procedures AAO-HNS supported as
effective and not considered investigational when part of a comprehensive approach in the
medical and surgical management of adults with OSA include tracheotomy, nasal and
pharyngeal airway surgery, tonsillectomy and adenoidectomy, palatal advancement, UPPP,
uvulopalatoplasty (including laser- assisted and other techniques), genioglossal advancement,
hyoid myotomy, midline glossectomy, tongue suspension, and maxillary and mandibular
advancement.
In its 2012 position statement on UPPP, AAO-HNS concluded that UPPP is a valid treatment of
OSA. Simultaneous and serial surgical procedures were considered medically necessary and
effective for patients with mild to severe obstructive sleep apnea.27 Another 2012 position
statement recommended tongue suspension as effective when considered as part of a
comprehensive approach in the medical and surgical management of adult patients with mild
OSA and in adult patients with moderate and severe OSA who have evidence of tongue base or
associated hypopharyngeal obstruction.28 AAO-HNS notes that results appear to diminish in
obese patients, and this technique should receive a weaker recommendation for these patients.
In 2011, AAO-HNS published clinical practice guidelines on polysomnography (PSG) for sleep-
disordered breathing before tonsillectomy in children.29 In addition to recommendations for PSG
(see Related Policies), AAO-HNS made the following recommendation: 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 10, oxygen saturation nadir
Page | 14 of 18
Medicare National Coverage
In 2001, the Centers for Medicare and Medicaid Services (CMS) published a decision
memorandum for CPAP that addressed the issue of how to define moderate to severe OSA as a
guide to a coverage policy for CPAP.31 Since surgical approaches are considered when CPAP
fails, the Medicare policy has been adapted to this policy on surgical management of OSA. The
Medicare review of the literature suggested that there is a risk of hypertension with an AHI
greater than 15, and thus treatment is warranted for these patients without any additional signs
and symptoms. For patients with an AHI between 5 and 15 and associated symptoms, the CMS
document concluded that the data from 3 RCTs demonstrated improved daytime somnolence
and functioning in those treated with CPAP.
Regulatory Status
In 1998, the Somnoplasty device was cleared for marketing by the U.S. Food and Drug
Administration (FDA) through the 510(k) process for radiofrequency ablation of palatal tissues
for simple snoring and for the base of the tongue for obstructive sleep apnea (OSA). FDA
product code: GEI.
In 1999, AIRvance (Medtronic; formerly the Repose Bone Screw System from Influence) was
cleared for marketing by the FDA though the 510(k) process for anterior tongue base
suspension by fixation of the soft tissue of the tongue base to the mandible bone using a bone
screw with prethreaded suture. It is indicated for the treatment of OSA and/or snoring. In 2011,
the Encore Tongue Suspension System (Siesta Medical) was cleared for marketing by the FDA
though the 510(k) process. The FDA determined that this device was substantially equivalent to
the PRELUDE III Tongue Suspension System (Siesta Medical). FDA product codes: LRK, ORY.
The Pillar Palatal Implant System (Restore Medical, St. Paul, MN, acquired by Medtronic,
Minneapolis, MN), an implantable device, was cleared for marketing by the FDA through the
510(k) process. The labeled indication of the device is as follows: The Pillar Palatal Implant
System is intended for the reduction of the incidence of airway obstructions in patients suffering
from mild to moderate OSA (obstructive sleep apnea). FDA product code: LRK.
In 2014, the Inspire II Upper Airway Stimulation System (Inspire Medical Systems) was
approved by the FDA through the premarket approval process. In 2011, Apnex Medical received
FDA approval to conduct a randomized investigational device exemption (IDE) trial for the
Hypoglossal Nerve Stimulation (HGNS) System. The trial was terminated and Apnex Medical
Page | 15 of 18
has ceased operations. In 2014, ImThera Medical received FDA approval to conduct an IDE trial
with the aura6000.
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28. American Academy of Otolaryngology-Head and Neck Surgery. Position Statement on Uvulopalatopharyngoplasty. 2012;
http://www.entnet.org/?q=node/896 Accessed May 2018.
29. American Academy of Otolaryngology-Head and Neck Surgery. Position Statement on Tongue Suspension. 2012;
http://www.entnet.org/Practice/policytonguesuspension.cfm Accessed May 2018.
30. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to
tonsillectomy in children. Otolaryngol Head Neck Surg. Jul 2011;145(1 Suppl):S1-15. PMID 21676944
31. American Society for Metabolic & Bariatric Surgery. Peri-operative management of obstructive sleep apnea. 2012
http://asmbs.org/resources/peri-operative-management-of-obstructive-sleep-apnea Accessed May 2018.
32. Centers for Medicare and Medicaid. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive
Sleep Apnea (OSA) (CAG-00093N). 2001, Oct 30. http://www.cms.gov/medicare-coverage-database/details/nca-decision-
memo.aspx?NCAId=19&ver=7&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy+for+Obstructive
+Sleep+Apnea+(OSA)&TAId=50&bc=AAAAAAAAEAAA& Accessed May 2018.
33. Blue Cross and Blue Shield Association. Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome. Medical Policy
Reference Manual, policy 7.01.101, 2016.
http://www.entnet.org/Practice/policySurgicalMgmtApnea.cfmhttp://www.entnet.org/content/position-statement-hypoglossal-nerve-stimulation-treatment-obstructive-sleep-apnea-osahttp://www.entnet.org/content/position-statement-hypoglossal-nerve-stimulation-treatment-obstructive-sleep-apnea-osahttp://www.entnet.org/?q=node/896http://www.entnet.org/Practice/policytonguesuspension.cfmhttp://asmbs.org/resources/peri-operative-management-of-obstructive-sleep-apneahttp://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=19&ver=7&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy+for+Obstructive+Sleep+Apnea+(OSA)&TAId=50&bc=AAAAAAAAEAAA&http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=19&ver=7&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy+for+Obstructive+Sleep+Apnea+(OSA)&TAId=50&bc=AAAAAAAAEAAA&http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=19&ver=7&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy+for+Obstructive+Sleep+Apnea+(OSA)&TAId=50&bc=AAAAAAAAEAAA&
Page | 17 of 18
History
Date Comments 07/14/14 New PR policy replacing 7.01.101. Medically necessary criteria for OSA diagnosis
expanded to include a threshold of an AHI of 15-30 events as a specific criterion.
When the AHI is 5-15, an additional requirement of documentation to evidence:
stroke, hypertension, ischemic heart disease; or, symptoms of impaired
cognition/mood disorder/insomnia; or, Epworth sleep scale greater than 10 or MSLT
less than 6 to evidence daytime sleepiness; or, more than 20 episodes of desaturation;
or obesity (BMI over 35). When the AHI is greater than 30, the patient must be able to
tolerate PAP or it must be contraindicated. Criteria for children updated to an
apneic/hypopneic index (AHI) greater than 1.5. ICD-9 and ICD-10 procedure and
diagnosis codes removed; they are not utilized in adjudication. Policy effective
subsequent to 2.01.532 effective October 23, 2014. Added investigational policy
statement for implantable hypoglossal nerve stimulators.
10/23/14 Reissue policy as updates are now effective; reference to previous version removed.
06/17/15 Annual Review. No change to policy statements. Informational CPT codes removed;
these are not reviewed.
02/09/16 Annual Review. Policy updated with literature review through January, 2016; reference
31 added; policy statements unchanged.
03/01/17 Annual Review, approved February 14, 2017. Policy updated with literature review
through October 4, 2016; references 17-20 added. Coding update; added codes,
including new CPT codes effective 1/1/17. No change to policy statements.
03/30/17 Policy moved into new format; no change to policy statements.
12/01/17 Interim Review, approved November 9, 2017. Policy updated with literature review
through July 20, 2017; reference 27 added, references 26,28, 29, 31, updated. Policy
statements unchanged. Removed CPT code 0468T.
01/01/18 Removed Related Policies 1.01.524, 2.01.503, and 2.01.532 as they were archived.
03/01/18 Interim Review, approved February 27, 2018. Note added that this policy has been
revised. Added Surgery Site of Service criteria, which becomes effective June 1, 2018.
06/01/18 Minor update; removed note and link to updated policy. Surgery Site of Service criteria
becomes effective.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review
Page | 18 of 18
and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit
booklet or contact a member service representative to determine coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). 2018 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members and their providers should consult the member
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
037336 (07-2016)
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