Anthem Blue Cross Connecticut SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring Form

This document addresses surgical treatments for obstructive sleep apnea (OSA), such as uvulopalatopharyngoplasty (UPPP), hyoid myotomy and jaw realignment surgery, laser surgery, radiofrequency ablation, palatal implants, and other procedures. This document does not address tonsillectomy, adenoidectomy or nasal surgery.

Note: For information related to other technologies utilized in the diagnosis and management of sleep-related disorders, please see:

• DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
• MED.00002 Selected Sleep Testing Services
• CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
• CG-SURG-36 Adenoidectomy

Note: Please see the following document for the use of nasal surgery to treat snoring and OSA

• CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

Position Statement

Medically Necessary:

Uvulopalatopharyngoplasty (UPPP):

Uvulopalatopharyngoplasty (UPPP) is considered medically necessary when all of the following criteria (A-D below) are met:

1. Documented OSA with apnea hypopnea index (AHI) or respiratory disturbance index (RDI) meeting any of the following:
   1. UPPP as sole procedure with AHI (or RDI) greater than 15 events per hour and less than 40 events per hour,
      or
   2. UPPP as sole procedure with AHI (or RDI) between 10-15 events per hour and one or more of the conditions listed below:
      1. Hypertension; or
      2. Cardiac arrhythmias predominately during sleep; or
      3. Pulmonary hypertension; or
      4. Documented ischemic heart disease; or
      5. Impaired cognition or mood disorders; or
      6. History of stroke; or
      7. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness Scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities.
         or
   3. UPPP as part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction, (for example, genioglossal advancement, hyoid myotomy and suspension) with AHI (or RDI) greater than 15 events per hour,
      or
   4. UPPP as part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction, (for example, genioglossal advancement, hyoid myotomy and suspension) with AHI (or RDI) between 10-15 events per hour and one or more of the conditions listed below:
      1. Hypertension; or
      2. Cardiac arrhythmias predominately during sleep; or
      3. Pulmonary hypertension; or
      4. Documented ischemic heart disease; or
      5. Impaired cognition or mood disorders; or
      6. History of stroke; or
      7. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness Scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities.
         and
2. Have failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period;
      and
3. Fiberoptic endoscopy suggests retro-palatal narrowing is the primary source of airway obstruction if UPPP is the sole procedure or a contributing source of airway obstruction if part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction;
   and
4. The individual is 18 years of age or older, or there is documentation that skeletal growth is complete based on long bone x-ray or serial cephalometrics showing no change in facial bone relationships for at least the last 3 consecutive months.

Soft Tissue Reconstruction:

Hyoid myotomy and suspension, with or without mandibular osteotomy with genioglossus (tongue) advancement, for the treatment of OSA is considered medically necessary when all of the following criteria (A-D below) are met:

1. The treatment of OSA in the individual is medically necessary based on either 1) or 2) below:
   1. AHI or RDI greater than or equal to 15 events per hour;
      or
   2. AHI (or RDI) greater than or equal to 5 events per hour, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
      1. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities; or
      2. Impaired cognition or mood disorders; or
      3. Hypertension; or
      4. Ischemic heart disease or history of stroke; or
      5. Cardiac arrhythmias, or
      6. Pulmonary hypertension.
         and
2. The individual has failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period;
      and
3. There are significant soft tissue and/or tongue base abnormalities with airway collapse. (Objective evidence of hypopharyngeal obstruction may be documented by either fiberoptic endoscopy or cephalometric radiographs.
   and
4. The individual is 18 years of age or older, or there is documentation that skeletal growth is complete based on long bone x-ray or serial cephalometrics showing no change in facial bone relationships for at least the last 3 consecutive months.

Jaw Realignment Surgery:

Jaw realignment surgery (that is, maxillomandibular advancement) is considered medically necessary when all of the following criteria (A-D below) are met:

1. The treatment of OSA in the individual is medically necessary based on either 1) or 2) below:
   1. AHI or RDI greater than or equal to 15 events per hour;
      or
   2. AHI (or RDI) greater than or equal to 5 events per hour, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
      1. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities; or
      2. Impaired cognition or mood disorders; or
      3. Hypertension; or
      4. Ischemic heart disease or history of stroke; or
      5. Cardiac arrhythmias, or
      6. Pulmonary hypertension.
         and
2. The individual has failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period;
      and
3. The individual has failed surgical intervention with any of the following:
   1. UPPP; or
   2. Genioglossus advancement and/or hyoid myotomy with suspension; or
   3. Both of these surgical procedures.
      and
4. The individual is 18 years of age or older, or there is documentation that skeletal growth is complete based on long bone x-ray or serial cephalometrics showing no change in facial bone relationships for at least the last 3 consecutive months.

Jaw realignment surgery is also considered medically necessary for individuals with a documented severe jaw/facial bony abnormality that contributes to OSA, including, but not limited to, craniofacial abnormalities, micrognathia, retrognathia or small retro-positioned jaw with associated overbite and small mouth.

Note: Individuals undergoing jaw realignment surgery may also undergo orthodontic therapy. Orthodontic therapy (that is, placement of orthodontic brackets and wires) may not be a covered benefit under all member benefit plans.

Hypoglossal nerve stimulation

Hypoglossal nerve stimulation may be considered medically necessary when all of the following criteria (A-E below) are met:

1. AHI or RDI greater than or equal to 15 events per hour and less than or equal to 65 events per hour; and
2. Central or mixed apneas make up less than 25% of total AHI or RDI score; and
3. Body Mass Index (BMI) of 32 or less; and
4. Absence of complete concentric collapse at the soft palate level during drug-induced sleep endoscopy; and
5. The individual has failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period.

In addition to the general criteria above, hypoglossal nerve stimulation may be considered medically necessary to treat OSA for individuals with Down Syndrome when all of the following criteria are met:

1. Individual is 10 years of age or older; and
2. AHI or RDI greater than or equal to 10 events per hour and less than or equal to 50 events per hour following adenotonsillectomy; and
3. Central or mixed apneas make up less than 25% of total AHI or RDI score; and
4. The individual’s body mass falls within the following age-based range:
   1. BMI less than or equal to the 95th percentile for individuals under age 18; or
   2. BMI of 32 or less in individuals age 18 or over; and
5. Absence of complete concentric collapse at the soft palate level during drug-induced sleep endoscopy; and
6. Inadequate treatment as evidenced by one or more of the following:
   1. Lack of benefit from positive airway pressure (PAP) treatment (for example, due to nonadherence, discomfort, undesirable side effects, or to persistent symptoms despite compliance), or
   2. Tracheotomy use during sleep.

Not Medically Necessary:

UPPP, soft tissue reconstruction, jaw realignment surgery, or hypoglossal nerve stimulation are considered not medically necessary when the criteria above are not met.

The surgical treatment of snoring without OSA is considered not medically necessary in all cases.

Investigational and Not Medically Necessary:

Other surgical treatments for OSA are considered investigational and not medically necessary.