HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-280-003
Topic:
Surgical Treatment of Obstructive Sleep Apnea
Section:
Surgery
Effective Date:
September 30, 2024
Issued Date:
October 14, 2024
Last Revision Date:
September 2024
Annual Review:
March 2024
 
 

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

Policy Position

Hypoglossal Nerve Stimulators - Adults

U.S. Food and Drug Administration (FDA) approved 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 22 years; and
  • AHI greater than or equal to 15 with less than or equal to 100 with less than 25 percent central apneas; and
  • CPAP failure (residual AHI greater than 15 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 35 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.

64582

64583

64584

 

 

 

 




Hypoglossal Nerve Stimulators – Adolescents or Young Adult with Down Syndrome and OSA

U.S. Food and Drug Administration (FDA) approved hypoglossal nerve stimulators may be considered medically necessary in adolescents or young adults with Down syndrome and OSA when ALL of the following criteria are met:

  • Age 10 to 21 years; and
  • AHI greater than or equal to 10 and less than or equal to 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 less than or equal to the 95th percentile 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.

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:

  • 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
  • Tracheostomy.

Surgical treatment of OSA not meeting the criteria as indicated in this policy is considered not medically necessary.

21122

21123

21195

21196

21199

21299

21685

31600

41120

41130

42145

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.

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:

  • 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.

31600

31601

42145

   

 

 



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.

41512

41530

42140

S2080

 

 

 



C9727

 

 

 

 

 

 




Related Policies

Refer to Medical Policy E-20, Devices Used for the Treatment of Obstructive Sleep Apnea in Adults, for additional information.

Refer to Medical Policy Z-8, Diagnosis of Obstructive Sleep Apnea in Adults for additional information.

Refer to Medical Policy Z-64, Diagnosis of Obstructive Sleep Apnea in Pediatric Individuals for additional information.

Refer to MCG Guideline A-0180, Adenoidectomy, for additional information.

Refer to MCG Guideline A-0181, Tonsillectomy, for additional information.

Refer to MCG Guideline A-0183, Turbinate Resection, for additional information.


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

 

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Surgical treatment of OSA is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting. is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.