Surgical Procedures - Adults
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date;
or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
The following surgical interventions may be considered medically necessary for the treatment of clinically significant OSA in adults who have failed an adequate trial of CPAP or failed an adequate trial of an oral appliance:
-
Adenoidectomy;
or
-
Adenotonsillectomy;
or
-
Hyoid suspension;
or
-
Maxillofacial surgery, including mandibular-maxillary advancement (MMA);
or
- Palatopharyngoplasty, including but not limited to:
-
Expansion sphincter pharyngoplasty;
or
-
Lateral pharyngoplasty;
or
-
Palatal advancement pharyngoplasty;
or
-
Relocation pharyngoplasty;
or
-
Uvulopalatal flap;
or
-
Uvulopalatopharyngoplasty (UPPP);
or
-
Tongue modification, surgical;
or
-
Tonsillectomy;
or
- Tracheostomy.
Surgical treatment of OSA not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
21195 | 21196 | 21199 | 21299 | 21685 | 31600 | 41120 |
41130 | 42145 | 42821 | 42826 | 42831 | 42836 | 42299 |
| 42999 |
