Surgical Treatment of Obstructive Sleep Apnea

Policy ID: S-280-001

Section: Surgery

Effective Date: July 03, 2023

Last Reviewed: May 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Surgical procedures may be used to treat obstructive sleep apnea (OSA) in adults and pediatric individuals.

Criteria

Hypoglossal Nerve Stimulators - Adults Hypoglossal nerve stimulators may be considered medically necessary in adults with OSA when ALL of the following criteria are met:

Age greater than or equal to 18 years; and
AHI greater than or equal to 15 with less than 25 percent central apneas; and
CPAP failure (residual AHI greater than 20 or failure to use CPAP greater than or equal to four (4) hours per night for five (5) or more nights per week) or inability to tolerate CPAP; and
Body mass index less than or equal to 32 kg/m2; and
Non-concentric retropalatal obstruction on Drug-Induced Sleep Endoscopy (DISE).

Use of hypoglossal nerve stimulators for the treatment of OSA not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

64582

64583

64584

Hypoglossal Nerve Stimulator - Adolescents or Young Adult with Down Syndrome and OSA

Hypoglossal nerve stimulation may be considered medically necessary in adolescents or young adults with Down syndrome and OSA under the ALL of the following conditions:

Age 10 to 21 years; and
AHI greater than 10 and less than 50 with less than 25 percent central apneas after prior adenotonsillectomy; and
Have EITHER:
- A tracheotomy; or
- Be ineffectively treated with CPAP due to noncompliance, discomfort, un-desirable side effects, persistent symptoms despite compliance use, or refusal to use the device; and
Body mass index greater than or equal to the 95th ^p ercentile for age; and
Non-concentric retropalatal obstruction on DISE.

Use of hypoglossal nerve stimulators for the treatment of OSA not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

64582

64583

64584

Surgical Procedures - Adults

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

21122

21123

21195

21196

21199

21299

21685

31600

41120

41130

42145

42821

42826

42831

42836

42299

42999

Experimental/Investigational Surgical Procedures - Adult

The following minimally invasive surgical procedures for treatment of OSA are considered experimental/investigational and, therefore, non-covered because the safety and effectiveness of these services cannot be established by the available published peer-reviewed literature:

Atrial overdrive pacing; or
Laser-assisted palatoplasty (LAUP) or radiofrequency volumetric tissue reduction of the palatal tissues; or
Laser-assisted tonsillectomy or laser ablation of the tonsils (LAT); or
Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent (CAPSO), and the implantation of palatal implants: or
Polypectomy; or
Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues; or
Septoplasty: or
Tongue base suspension; or
Turbinectomy: or
Uvulectomy: or
All other minimally invasive surgical procedures not described above.

Procedure Codes

30130

30140

30520

31237

41512

41530

42140

93799

S2080

Surgical Procedures - Pediatric

The following surgical interventions to treat clinically significant OSA in pediatric individuals may be considered medically necessary for ANY of the following:

Adenoidectomy; or
Adenotonsillectomy; or
Tonsillectomy; or
Uvulopalatopharyngoplasty (UPPP) in pediatric individuals with neuromuscular disorders who are deemed to be at high risk for persistent upper airway obstruction after adenotonsillectomy alone; or
Other surgical options available for pediatric individual's not responding to usual treatment include:
- Craniofacial surgery; or
- Tracheostomy in severe cases.

Procedure Codes

31600

31601

42145

42820

42821

42825

42826

42830

42831

42835

42836

Pharyngoplasty (plastic or reconstructive operation on pharynx) is considered Experimental/Investigational/Unproven for the treatment of sleep apnea

Procedure Code

42950

Experimental/Investigational Surgical Procedures - Pediatric

The following surgical interventions are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature may include but is not limited to:

Laser-assisted palatoplasty or radiofrequency volumetric tissue reduction of the palatal tissues; or
Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues; or
Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent, and the implantation of palatal implants; or
Tongue base suspension; or
Uvulectomy ; or
All other minimally invasive surgical procedures not described above.

Procedure Codes

41512

41530

42140

S2080

Outpatient HCPCS (C Codes)

C9727

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 64582, 64583, 64584

G47.33

Q90.0

Q90.1

Q90.2

Q90.9

Non-Covered Diagnosis Codes for Procedure Codes: 30130, 30140, 30520, 31237, 41512, 41530, 42140, 42145, C9727, S2080

G47.33

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-23-2023 Adopted new policy - Effective July 03, 2023

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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Medical Policies Quick Search

Surgical Treatment of Obstructive Sleep Apnea

Description

Criteria

Procedure Codes

Procedure Codes

Procedure Codes

Procedure Codes

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer