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
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 |
