Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty, relocation pharyngoplasty) may be considered medically necessary for the treatment of clinically significant obstructive sleep apnea (OSA) syndrome in appropriately select adults who have failed an adequate trial of continuous positive airway pressure (CPAP) or failed an adequate trial of an oral appliance. Clinically significant OSA is defined as those individuals who have:
Apnea/Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of 15 or more events per hour, or
AHI or RDI of at least 5 events per hour with 1 or more signs or symptoms associated with OSA (eg, excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke).
Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA), may be considered medically necessary in appropriately selected adults with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have failed an adequate trial of CPAP or failed an adequate trial of an oral appliance. Clinically significant OSA is defined as those individuals who have:
AHI or RDI of 15 or more events per hour, or
AHI or RDI of at least 5 events per hour with 1 or more signs or symptoms associated with OSA (eg, excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke).
Adenotonsillectomy may be considered medically necessary in pediatric individuals with clinically significant OSA and hypertrophic tonsils. Clinically significant OSA is defined as those pediatric individuals who have:
AHI or RDI of at least 5 per hour, or
AHI or RDI of at least 1.5 per hour in anindividual with excessive daytime sleepiness, behavioral problems, or hyperactivity.
Hypoglossal nerve stimulation may be considered medically necessary in adults with OSA under the following conditions:
Age ≥ 22 years; AND
AHI ≥ 15 with less than 25% central apneas; AND
CPAP failure (residual AHI ≥ 15 or failure to use CPAP ≥ 4 hr per night for ≥ 5 nights per week) or inability to tolerate CPAP; AND
Body mass index ≤ 32 kg/m2; AND
Non-concentric retropalatal obstruction on drug-induced sleep endoscopy (see Policy Guidelines).
Hypoglossal nerve stimulation may be considered medically necessary in adolescents or young adults with Down syndrome and OSA under the following conditions:
Age 10 to 21 years; AND
AHI >10 and <50 with less than 25% central apneas after prior adenotonsillectomy; AND Have either tracheotomy or be ineffectively treated with CPAP due to noncompliance, discomfort, undesirable side effects, persistent symptoms despite compliance use, or refusal to use the device; AND Body mass index ≤ 95th percentile for age; AND Non-concentric retropalatal obstruction on drug-induced sleep endoscopy (See Policy Guidelines). Surgical treatment of OSA that does not meet the criteria above would be considered not medically necessary. The following minimally invasive surgical procedures are considered investigational for the sole or adjunctive treatment of OSA or upper airway resistance syndrome: Laser-assisted palatoplasty or radiofrequency volumetric tissue reduction of the palatal tissues Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent, and the implantation of palatal implants Tongue base suspension All other minimally invasive surgical procedures not described above. Implantable hypoglossal nerve stimulators are considered investigational for all indications other than listed above. All interventions, including laser-assisted palatoplasty, radiofrequency volumetric tissue reduction of the palate, or palatal stiffening procedures, are considered investigational for the treatment of snoring in the absence of documented OSA; snoring alone is not considered a medical condition.
