Surgical procedures may be used to treat obstructive sleep apnea (OSA) in adults and pediatric individuals.
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:
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:
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:
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:
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:
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:
41512 |
41530 |
42140 |
S2080 |
|
|
|
C9727 |
|
|
|
|
|
|
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 |
|
|
|
|
|
|
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:
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:
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.
