Durable Medical Equipment (DME) - Positive Airway Pressure (PAP) Devices, Oral Devices, and Hypoglossal Nerve Stimulation Devices for the Treatment of Obstructive Sleep Apnea Article Form

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Durable Medical Equipment (DME): Positive Airway Pressure (PAP) Devices, Oral Appliance Devices, and Hypoglossal Nerve Stimulation Devices for the Treatment of Obstructive Sleep Apnea Medical Guideline

Service: DME: Positive Airway Pressure (PAP) Devices, Oral Appliance Devices, and Hypoglossal Nerve Stimulation Devices (CPAP, BPAP, BiPAP®, BiPAP® ST, BiPAP® with backup, BiPAP®-Auto SV, VPAP, VPAP™Adapt, VPAP™ adapt SV, APAP, Adaptive Servo-Ventilation, ASV, oral device, mandibular advancement device, Hypoglossal nerve stimulation) for the Treatment of Obstructive Sleep Apnea

PUM 250-0031-1721

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Coverage for durable medical equipment (DME) varies across plans. Refer to the member’s benefit plan document for coverage details.

Related Medical Guidelines:

• Durable Medical Equipment (DME): Positive Airway Pressure (PAP), Oral Devices, and Hypoglossal Nerve Stimulation Devices for the Treatment of Obstructive Sleep Apnea Article • General DME Medical Guideline
• Sleep Disorder Testing Medical Guideline

 Note: Coverage for Positive Airway Pressure (PAP) and related devices are also subject to the individual’s health plan language for Durable Medical Equipment (DME).

Description:

This guideline addresses the following treatments:

An Oral Appliance, also called: mandibular advancement device (MAD), mandibular advancement appliance (MAA), mandibular repositioning appliances (MRA), or mandibular advancement splint (MAS), is a device used to modify an individual’s airway during sleep to decrease the symptoms associated with obstructive sleep apnea (OSA).

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Positive Airway Pressure (PAP) devices provide respiratory assistance through the administration of positive air pressure through a nasal or oral mask for the treatment of sleep disordered breathing.

CPAP (continuous positive airway pressure) provides a continuous set level of airway pressure during both inspiration (breathing in) and expiration (exhaling, breathing out).

BPAP or BiPAP (bi-level positive airway pressure) provides positive airway pressure at a set level during inspiration but allows a different level of positive airway pressure to be set during expiration. BPAPs are available with and without back up features.

ASV (adaptive-servo-ventilation) provides a varying amount of inspiratory pressure superimposed on a low level of CPAP, with a backup respiratory rate. It is used as second-line therapy for patients with hyperventilation-related central sleep apnea who have failed or do not tolerate CPAP.

APAP (Automatic Positive Airway Pressure; also called CPAP with auto-titration, autoPAP, and auto-titrating positive airway pressure) can be used to titrate PAP therapy in the individual’s home.

VPAP (variable positive airway pressure) devices provide variable levels of airway pressure during inspiration and expiration, responding to the needs of the individual.

Hypoglossal nerve stimulation (HGNS) (e.g., Inspire Upper Airway Stimulation [UAS] System) utilizes an implantable pulse generator, a respiratory-sensing lead and a stimulating lead surgically placed on the hypoglossal nerve. Mild electrical stimulation to the hypoglossal nerve produces selective motor stimulation of the muscle fibers that draw the tongue forward via activation of the genioglossus muscle, which improves upper airway obstruction. The individual uses a remote control to turn the device on before going to sleep and turn it off upon awakening.
HGNS is intended to be a lifelong therapy.

**This guideline does not address other surgical services used to treat OSA. For these services, such as Uvulopalatopharyngoplasty (UPPP), refer to current medical references and/or specialty society guidelines, such as, MCG A-0245 Uvulopalatopharyngoplasty (UPPP), A-0246 Uvulopalatopharyngoplasty (UPPP), Alternative Procedures.

Definitions:

A Sleep Medicine Specialist, for purpose of this guideline, is one of the following:

• A Diplomate of the American Board of Sleep Medicine or
• A certification in sleep medicine and one of the following Board-Certified Specialties:
Pulmonologist, Otolaryngologist, Neurologist, Pediatrician, Internist, Family Medicine Physician, Psychiatrist, or Nurse Practitioner or Physician Assistant working in collaboration with one of the listed specialists.

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Compliance, for the purpose of this guideline, is defined as a minimum of four hours of use per night for 70% of the nights of a three-month trial. A three-month trial rental of PAP device to allow for time to optimize conditions for tolerance/compliance and to document compliance is required prior to purchase of a PAP device or approval of an oral appliance.

Apnea is defined as the cessation of airflow for at least 10 seconds.

Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation.

Severe chronic obstructive pulmonary disease (COPD), for the purpose of this guideline, is defined as post bronchodilator FEV1(forced expiratory volume)/FVC (forced vital capacity) ratio less than 0.7, FEV1 less than 30 percent predicted.

Apnea Hypopnea Index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. For purposes of this guideline, respiratory effort related arousals (RERAs) are not included in the calculation of the AHI. Sleep time can only be measured in a Type I (facility based polysomnogram) or Type II sleep study (see descriptions below).

Respiratory Disturbance Index (RDI) is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure device. For purposes of this guideline, respiratory effort related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type IV, and other home sleep studies.

*If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that would have been required in a 2 hour period (i.e., must reach ≥ 30 events without symptoms or ≥ 10 events with symptoms).

Respiratory Event Index (REI)-index used to describe the number of apneas and hypopneas when using a Home Sleep Apnea Test (HSAT) per total recording time.

Respiratory event-related arousals (RERAs) are respiratory event related arousals from sleep that may be seen during a sleep study with EEG. The degree of hypoxia is not low enough to fulfill the criteria for apnea or hypopnea but does result in brief arousal.

Obstructive Sleep Apnea (OSA) is a sleep related breathing disorder that involves a decrease in, or complete lack of, airflow, despite an ongoing effort to breath. The severity of OSA is divided into three categories based on the result of the PSG. Mild (AHI of 5-15), Moderate (AHI of 15-30) and Severe (AHI of over 30).

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Indications of Coverage:

A. AutoPAP (APAP) or CPAP with or without a humidifier (heated or non-heated) is considered medically necessary for the treatment of any of the following conditions (1, 2, 3, or 4 below):

1. Obstructive sleep apnea that has been diagnosed though a Type I, II, or III polysomnogram with an in-lab AHI or home study RDI or REI of 15 or more with a minimum of 30 events.

2. Obstructive sleep apnea that has been diagnosed though a Type 1, Type II, or Type III polysomnogram with an in-lab AHI or home study RDI or REI between 5 and 15 with a minimum of 10 events and:

   The individual has at least one of the following co-morbidities or symptoms (a. through j. below):

   a. Presence of cardiac arrhythmias unstable or refractory to treatment

   b. Unexplained pulmonary hypertension

   c. Hypertension (high blood pressure)

   d. Body mass index (BMI) greater than 40

   e. Cerebrovascular disease (Stroke)

   f. Congestive Heart Failure (CHF) includes New York Heart Association (NYHA) class III or IV, left ventricular ejection fraction (LVEF) less than 45%

   g. Excessive Daytime Sleepiness defined as an Epworth score over 10

   h. Cognitive dysfunction attributed to sleep diagnosed using one of the following clinically recognized cognitive assessment tools:

   1) California Verbal Learning Test 2) Digit Span (from the Wechsler Adult Intelligence Scale-Revised) 3) Informant Questionnaire on Cognitive Decline in the Elderly 4) Mini-Mental State Examination (MMSE) 5) Montreal Cognitive Assessment (MoCA) test
   6) Trails A or B OR 7) Current use of medication for dementia

   i. Depression requiring antidepressant therapy

   j. Ischemic Heart Disease

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3. Central Sleep Apnea

4. Obesity Hypoventilation

   B. BPAP (BiPAP) without back up (with or without a humidifier) is considered medically necessary for the treatment of any of the following conditions:

5. Obstructive Sleep Apnea (OSA): Member met the criteria above (A., 1. or 2.) for CPAP and either of the following:

   a. Documentation from a sleep medicine physician reporting the failure of a one-month trial of CPAP or AutoPAP due to intolerance to high pressures that exceed 10cm H2O despite adequate changes to headgear and masks. A download from the CPAP device documenting a minimum of four hours of use per night for 70% of the nights of the one-month trial is required.

   b. Documentation from a laboratory titration study indicating failure to meet therapeutic goals with CPAP or AutoPAP (e.g., BPAP needed due to hypoxia or inadequate reduction of AHI with CPAP).

   NOTE: For BiPAP for individuals with chronic respiratory failure, respiratory insufficiency (hypoxia and/or hypercapnia), refer to current medical references and/or specialty society guidelines, such as, MCG, Bilevel Positive Airway Pressure (BPAP) Device ACG: A-0994 (AC).

   C. BPAP with back up is considered medically necessary when prescribed by a Sleep Medicine Specialist for the treatment of any the following conditions:

6. Neuromuscular disease (for example, amyotrophic lateral sclerosis) or significant thoracic anatomical abnormalities (e.g., post thoracic surgery deformity), when there is documentation from laboratory attended polysomnogram indicating failure of BPAP without back up to meet therapeutic goals, and there is significant improvement of sleep associated hypoventilation on the device prescribed for use at home.

7. Severe COPD, when there is documentation from laboratory attended polysomnogram indicating failure of BPAP without back up to meet therapeutic goals, and there is significant improvement of sleep associated hypoventilation on the device prescribed for use at home.

8. Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA) documented by a laboratory attended polysomnogram, when use of CPAP alone has proved ineffective, and there is significant improvement of sleep associated hypoventilation/ hypoxia on the device and setting that will be prescribed for use at home.

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NOTE: For BiPAP for individuals with chronic respiratory failure, respiratory insufficiency (hypoxia and/or hypercapnia), refer to current medical references and/or specialty society guidelines, such as, MCG, Bilevel Positive Airway Pressure (BPAP) Device ACG: A-0994 (AC).

D. Adaptive Servo Ventilation: (e.g., VPAP™Adapt with Adaptive Servo Ventilation [ASV]) or BPAP (with auto Servo Ventilation [SV]) are considered medically necessary when the device is prescribed by a Sleep Medicine Specialist and there is documentation that BPAP with or without backup has failed or is contraindicated, and there is significant improvement during laboratory titration on the device that has been prescribed for the treatment of any of the following conditions:

1. Primary Central Sleep Apnea (does not require BPAP trial)

2. Central Sleep Apnea except in patients with symptomatic heart failure with left ventricular ejection fraction (LVEF) less than or equal to 45%

3. Complex Sleep Apnea or treatment-emergent central sleep apnea

4. Sleep Apnea with comorbidity of congestive heart failure (CHF)

5. Hypoventilation Syndrome

   E. Rental, Continued Coverage, and Purchase of PAP Devices:

   If the criteria for the specific PAP device (A., B., C., or D) is met:

   A rental of three months may be approved.

   For continued coverage beyond the first three months of therapy: A separate prior authorization request must be submitted prior to the end of the three-month rental period and include an in-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved; and objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. Adherence to therapy is defined as use of PAP ≥ 4 hours per night on 70% of nights during a 60-day period (two month) device download. If the above criteria are not met, continued coverage will be considered not medically necessary due to non-compliance.

   *Members who fail the initial 12-week trial are eligible to re-qualify for a PAP device but must have both:

6. In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy; and

7. Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.

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For purchase of a device: A separate prior authorization request must be submitted prior to the end of the three-month rental period and include a 60-day (two month) device download that documents a minimum of four hours of use per night for at least 70% of the nights. If download documents non-compliance, purchase of CPAP will be considered not medically necessary due to non- compliance. Payment of rental charges beyond the purchase price of the device is a limitation of many of our member health plans and provider contracts.
.
F. Replacement of PAP Devices:

1. Replacement of CPAP or APAP device is considered medically necessary every 5 years provided there is documentation of a download compliance on the machine. If a download compliance is not available, a 3-month rental would be approved, with convert to purchase of the unit if compliance is documented with the 3-month rental. (Note: This applies to CPAP and APAP only, not BPAP, ASV, VPAP)

2. Replacement of CPAP or APAP device prior to 5 years or for replacement of other type of PAP device, the following documentation must be provided:

   a. The reason PAP device replacement is needed (problem or malfunction of the device; submit repair / replacement estimate when applicable).

   b. Medical records including all of the following: History, indications for the original PAP device (for example AHI and Epworth score), a download from the PAP device currently being used that shows a minimum of four hours of use per night for 70% of the nights of the last month, and effectiveness of PAP (or change in symptoms if the device is not working).

   NOTE: Replacement needed due to misuse, abuse, or member convenience will not be covered.

   NOTE: Rental of replacement device may be required prior to purchasing the device.

   G. An Oral Appliance (Mandibular Advancement Devices) for treatment of obstructive sleep apnea in an adult is considered medically necessary when all the following criteria (1. through

3. below) are met:

4. A polysomnogram documented the presence of mild or moderate (e.g., AHI below 30) obstructive sleep apnea sufficient to meet criteria for the use of a Positive Airway Pressure (PAP) device (see this guideline, Section A., 1. and 2. for criteria)

5. A two-month trial of the PAP device has failed. Failure of the PAP trial is defined as intolerance of the high pressures needed to maintain airway patency despite documentation by a Sleep Medicine Specialist of appropriate interventions to improve compliance (e.g., changes to masks and headgear, and support to address side effects and behavioral issues).

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The documentation must support the individual has been compliant with recommendations for PAP device use, as evidenced by a download from the PAP device that documents a minimum of 4 hours of use per night for 70% of the nights of the two-month trial.

3. A custom-fitted or prefabricated oral appliance is prescribed in the context of a comprehensive sleep program, after an evaluation by a Sleep Medicine Specialist. The evaluation must include documentation by the Sleep Medicine Specialist of PAP intolerance or contraindication as well as interventions that were tried to improve tolerance/compliance (e.g., changes to masks and headgear, and support to address side effects and behavioral issues).

4. The oral appliance is provided by a licensed dentist or sleep medicine specialist.

   NOTE: Aside from one follow up home polysomnogram to ensure therapeutic benefit after final fitting/adjustment of the oral appliance, all follow up care including (but not limited to) adjustments, modifications, and professional services are considered incidental to / included in the oral appliance primary service.

   Replacement of Oral Appliance: Review member’s certificate/plan for replacement purchase versus repair of oral appliance. Documentation should include the reason replacement is needed (submit repair / replacement estimate when applicable). Medical records should include history, including indications for the original device (for example AHI, Epworth scores when available), recent use history and effectiveness of device (or change in symptoms if the device is not working). Replacement due to misuse, abuse or member convenience may not be covered.

   H. Hypoglossal nerve stimulation (Inspire) for OSA

   Hypoglossal nerve stimulation (e.g., Inspire Upper Airway Stimulation System) is considered medically necessary for the treatment of moderate to severe obstructive sleep apnea when ALL of the following criteria are met:

5. Member is 18 years of age or older

6. Body mass index (BMI) is less than 32 kg/m2

7. A Polysomnography (PSG) is performed no more than 24 months prior to the first consultation for Inspire implant.

8. Member has predominantly obstructive events (defined as central and mixed apneas

   less than 25% of the total AHI).

9. Apnea hypopnea index (AHI) is 15 to 65 events per hour.

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6. Member has a minimum of one month of CPAP monitoring documentation that

   demonstrates CPAP failure (defined as AHI greater than 15 despite CPAP usage)

   or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week) despite

   reasonable attempts with multiple (2 or more) mask trials over at least 30 days. PAP

   intolerance must be documented by a Sleep Specialist.

7. Absence of complete concentric collapse at the soft palate level as seen on a drug-

   induced sleep endoscopy (DISE) procedure.

8. No other anatomical findings that would compromise the performance of device (e.g.,

   tonsil size 3 or 4 per tonsillar hypertrophy grading scale).

   H. Supplies and Accessories:

   For DME supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DME products (A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046) that are supplied as refills to the original order, suppliers must contact the member, and document an affirmative response, prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the member. This shall be done to ensure that the refilled item remains medically necessary, existing supplies are expected to end, and to confirm any changes or modifications to the order. Contact with the member or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply. For delivery of refills, the supplier must deliver the DME product no sooner than 10 calendar days prior to the expected end of the current supply.

   For all DME items that are provided on a recurring basis, suppliers are required to have contact with the member or caregiver/designee and document an affirmative response, prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request and an affirmative response from a member. Items delivered without a valid, documented refill request will be considered not medically necessary.

   Suppliers must not dispense a quantity of supplies exceeding a member's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioners that any changed or atypical utilization is warranted.

   Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity at a time.

   Either a non-heated (E0561) or heated (E0562) humidifier is covered when ordered by the treating practitioner for use with a covered PAP (E0470 or E0601) device.

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ACCESSORIES:

Accessories used with a PAP device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be considered not medically necessary.

The following table represents the usual maximum amount of accessories expected to be medically necessary:

A4604 1 per 3 months A7027 1 per 3 months A7028 2 per 1 month A7029 2 per 1 month A7030 1 per 3 months A7031 1 per 1 month A7032 2 per 1 month A7033 2 per 1 month A7034 1 per 3 months A7035 1 per 6 months A7036 1 per 6 months A7037 1 per 3 months A7038 2 per 1 month A7039 1 per 6 months A7046 1 per 6 months

Quantities of supplies greater than those described in the guideline as the usual maximum amounts will be considered not medically necessary.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements (Note: For medical diagnoses, the oral appliance would not process under the dental benefit.)

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B. If requested/used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If requested/used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary.

D. An oral appliance for the treatment of snoring without documentation of obstructive sleep apnea will be considered not a covered benefit, as snoring is not considered to be an illness or injury.

E. Only one sleep apnea treatment (either an oral appliance or a PAP device) may be approved for use at the same time. Deny per plan/certificate language. In the absence of specific plan/certificate language, it will be considered not medically necessary.

F. An oral appliance will be considered not medically necessary in any of the following situations:

1. When there is no polysomnogram documenting the presence of obstructive sleep apnea

2. In absence of the failure of a two-month trial of PAP device. Failure of the PAP trial is defined as intolerance of the high pressures needed to maintain airway patency despite documentation of appropriate interventions to improve compliance (e.g., changes to masks and headgear, and support to address side effects and behavioral issues). Intolerance and interventions tried must be documented by a Sleep Medicine Specialist.

3. When the device is obtained over the counter without a prescription

   G. A Hypoglossal Nerve Stimulation (Inspire Upper Airway Stimulation) System will be considered not medically necessary in any of the following situations:

4. Non-FDA-approved hypoglossal nerve neurostimulation will be considered not medically necessary for the treatment of adult obstructive sleep apnea due to insufficient evidence of safety and effectiveness.

5. Will be considered not medically necessary when any of the following contraindications are present:

   a. Central + mixed apneas > 25% of the total apnea-hypopnea index (AHI).

   b. Any anatomical finding that would compromise the performance of upper airway stimulation, such as the presence of complete concentric collapse of the soft palate, tonsil size 3 or 4 per standardized tonsillar hypertrophy grading scale, history of surgical resections or radiation therapy treatment for cancer of the larynx, tongue or throat without

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physician statement addressing why these do not preclude effective device use.

c. Coexisting non-respiratory sleep disorders that would confound functional sleep assessment

d. An active, serious mental illness that reduces the ability to carry out Activities of Daily Living (ADL’s) and would interfere with the patient’s ability to operate the Hypoglossal nerve stimulator and report problems to the attending provider.

e. Persistent uncontrolled hypertension despite medication use

f. Recent myocardial infarction or severe cardiac arrhythmias (within the past 6 months)

g. New York Heart Association class III or IV heart failure

h. Severe valvular heart disease

i. Moderate-to-severe pulmonary arterial hypertension

j. Severe restrictive or obstructive pulmonary disease

k. Hypoglossal-nerve palsy

l. Neuromuscular disease

m. Any conditions or procedure that has compromised neurological control of the upper airway.

n. Patients who are unable to or do not have the necessary assistance to operate the sleep remote.

o. Patients who are pregnant or plan to become pregnant.

p. Patients who will require magnetic resonance imaging (MRI).

q. Patients with an implantable device that may be susceptible to unintended interaction with the Inspire system. Consult the device manufacturer to assess the possibility of interaction.

r. Use of Inspire in patients with BMI > 32 kg/m2 is not recommended due to unknown effectiveness and safety.

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I. Drug Induced Sleep Endoscopy when used for any indication other than to evaluate if the patient is an appropriate candidate for hypoglossal nerve stimulation to treat obstructive sleep apnea.

J. ASV to treat central sleep apnea in patients with symptomatic, chronic heart failure (NYHA 2- 4) with reduced left ventricular ejection fraction (LVEF) ≤45% and moderate to severe predominant central sleep apnea is contraindicated.

I. The following will be considered experimental, investigational, and unproven to affect health

outcomes or not covered per the member health plan:

1. Expiratory Positive Airway Pressure [EPAP] (UltePAP, Bongo Rx, Provent® nasal dilator)

   2.Nasal dilators

2. Nonsurgical electric muscular stimulation (e.g., eXciteOSA)

3. Oral Pressure Therapy (OPT) or Oral Pressure appliance treatments intended to
   regulate oral pressure to treat OSA (e.g., Winx® Sleep Therapy System)

4. Silent Partner® or other type of noise canceling device to suppress snoring

5. Phrenic Nerve Stimulation (also known as diaphragm pacing, or atrial overdrive pacing) for Central Sleep Apnea (e.g., remede® System)

6. The Morning Repositioner® (daytime alignment device)

7. NightBalance (Phillips), Lunoa System (positional sleep therapy devices)

8. Somryst (Pear Therapeutics Inc.) Digital Therapeutic for Treatment of Chronic Insomnia (cognitive behavioral therapy)

9. Radiofrequency Ablation and radiofrequency volumetric tissue reduction (RFVTR)
   of palate and/or tongue for snoring or obstructive sleep apnea will be considered experimental, investigational, unproven.

10. Minimally Invasive Tongue Base Reduction Procedures for Treatment of Obstructive Sleep Apnea.

11. Playing of Wind Instruments for Treatment of Sleep-Related Breathing Disorders.

12. Hyoid suspension for treatment of obstructive sleep apnea.

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K. PAP cleaning devices and supplies (e.g., SoCleane2® CPAP Cleaner and Sanitizing Machine) will be considered convenience items (Most member plans have a general exclusion for convenience items). In the absence of plan language, these will be considered not medically necessary.

L. Devices considered duplicate, to include Back up units, travel units (ResMed Air Mini CPAP), or secondary units will be considered a health plan exclusion.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Sleep study (polysomnogram) report • Medical record information (including continued need/use if applicable) and medical necessity, documenting comorbidities or other issues relevant to use of the PAP device • Additionally, for purchase of a PAP device: Device download to demonstrate compliance during initial rental period • Additionally, for an oral appliance: Sleep Medicine Specialist documentation of PAP device intolerance or contraindication and interventions tried by the individual to improve tolerance (e.g., changes to masks and headgear, and support to address side effects and behavioral issues)
• Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. Durable Medical Equipment DME is only considered “durable” if it is prescribed by a qualified healthcare provider for a medical reason and is not typically useful to someone without a health condition. The equipment is primarily intended for use in the patient’s home.

DME including PAP, oral devices and hypoglossal nerve stimulation is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

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State mandates, laws or benchmark supersede this medical guideline. Guideline Review History:

Implemented 04/01/15, 04/01/16, 01/01/17, 04/01/18, 01/01/19, 01/01/20, 09/01/2020, 03/01/21, 05/01/21, 09/01/22, 09/01/23, 07/01/24, 01/01/26, 05/01/26 Medical Guideline Committee Approval 12/13/13, Erratum corrected 03/31/14, 12/12/14, 12/12/15, 12/09/16, 12/01/17, 09/21/18, 08/30/19, 03/26/20, 02/25/21, 04/29/21, 04/28/22, 04/27/23, 03/28/24, 03/27/25, Q1 2026 Reviewed

12/12/14, 12/12/15, 12/09/16, 12/01/17, 09/21/18, 08/30/19, 03/26/20, 04/29/21, 04/28/22, 04/27/23, 03/28/24, 03/27/25, Q1 2026 Developed

 Note: For review/revision history prior to 2014 see previous Medical Guideline

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 21685 Hyoid myotomy and suspension
33276 Insertion of phrenic nerve stimulator system (Pulse generator and stimulating leads[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed
33277 Insertion of phrenic nerve stimulator transvenous sensing lead (list separately in addition to code for primary procedure)
33278 Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generator and lead(s)
33279 Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed, transvenous stimulation or sensing lead(s) only
33280 Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only
33281 Repositioning of phrenic nerve stimulator transvenous lead(s)
33287 Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator

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33288 Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation of sensing lead(s)
42975
Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep-disordered breathing, flexible, diagnostic
64568 Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator (when used for Inspire treatment)
64582 Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array
64583 Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator
93150 Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming
93151 Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system
93152 Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography
93153 Interrogation and programming of implanted phrenic nerve stimulator system
94660 Continuous positive airway pressure ventilation (CPAP), initiation and management
C8007 Open implantation of hypoglossal nerve neurostimulator assay and pulse generator, not requiring insertion of a separate distal respiratory sensor electrode or electrode array
C8008 Revision or replacement of hypoglossal nerve neurostimulator array including connection to existing pulse generator
C8009 Removal of hypoglossal nerve neurostimulator array and pulse generator
C8011 Open implantation of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver, including external power source and all system components
C8012 Revision or replacement of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver
C8013 Removal of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver
E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device

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E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustment or non- adjustable, prefabricated, includes fitting and adjustment
E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustment or non- adjustable, custom fabricated, includes fitting and adjustment
E0490 Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by hardware remote
E0491 Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hardware remote, 90-day supply
E0492 Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application
E0493 Oral device, appliance for neuromuscular electrical stimulation of the tongue muscle used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply
E0530 Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type
E0561 Humidifier, non-heated, used with positive airway pressure device
E0562 Humidifier, heated, used with positive airway pressure device
E0601 Continuous positive airway pressure (CPAP) device

Associated Procedure Codes Code Description A4604 Tubing used with a heated humidifier and has heated wire running the length of the tube
A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each
A7028 Oral cushion for combination oral/nasal mask, replacement only
A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair
A7030 Full face mask used with positive airway pressure device, each
A7031 Face mask interface, replacement for full face mask, each
A7032 Cushion for use on nasal mask interface, replacement only, each
A7033 Pillow for use on nasal cannula type interface, replacement only, pair
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 Headgear used with positive airway pressure device
A7036 Chinstrap used with positive airway pressure device
A7037 Tubing used with positive airway pressure device
A7038 Filter, disposable, used with positive airway pressure device

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A7039 Filter, non-disposable, used with positive airway pressure device
A7044 Oral interface used with positive airway pressure device, each
A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only
A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each
A7049 Expiratory positive airway pressure, intra nasal resistance valve
K1027 Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment
K1037 Docking station for use with oral device/appliance used to reduce upper airway collapsibility
5A09357 Assistance with respiratory ventilation, less than 24 consecutive hours, continuous positive airway pressure
5A09457 Assistance with respiratory ventilation, 24-96 consecutive hours, continuous positive airway pressure
5A09557 Assistance with respiratory ventilation, greater than 96 consecutive hours, continuous positive airway pressure