130 Form

1

Medical Policy Surgical and Non-CPAP Treatment of Snoring and Obstructive Sleep Apnea Syndrome Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History
• Endnotes Policy Number: 130

BCBSA Reference Number: 7.01.101; 2.01.18 (For Plan internal use only) Related Policies
Home Cardiorespiratory Monitoring, #224 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Palatopharyngoplasty 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 selected 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) 15 or more events per hour, OR • AHI or RDI 5 or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

Hyoid suspension Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular- maxillary advancement (MMA), may be considered MEDICALLY NECESSARY in appropriately selected adult individuals with clinically significant OSA and objective documentation of hypopharyngeal obstruction 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:

• AHI or RDI 15 or more events per hour, OR • AHI or RDI 5 or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

2

Adenotonsillectomy Adenotonsillectomy may be considered MEDICALLY NECESSARY in children (2 -18 years of age) with obstructive sleep apnea and hypertrophic tonsils as determined through individual history and clinical exam. A polysomnography is recommended in individuals with sleep-disordered breathing in certain conditions1, see below:

The American Academy of Otolaryngology - Head and Neck Surgery Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children recommends a polysomnography in the following clinical circumstances.

• The clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. • The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing.

Surgical treatment of OSA 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.

All interventions, including laser-assisted palatoplasty, radiofrequency volumetric tissue reduction of the palate, or palatal stiffening procedures, are NOT MEDICALLY NECESSARY for the treatment of snoring in the absence of documented OSA; snoring alone is not considered a medical condition.

Non-CPAP Medical Treatment of OSA2 The use of an abbreviated daytime sleep session for acclimation to CPAP (PAP-NAP) is considered INVESTIGATIONAL.

The use of a sleep positioning trainer with vibration is considered INVESTIGATIONAL for the treatment of positional OSA.

The use of daytime electrical stimulation of the tongue is considered INVESTIGATIONAL for the treatment of OSA.

Nasal expiratory positive airway pressure (EPAP) and oral pressure therapy devices are considered INVESTIGATIONAL.

For medically necessary indications on APAP, CPAP, BPAP, see Carelon Medical Benefits Management Clinical Guidelines for Sleep Disorder.

3

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required for sleep apnea surgery (CPT codes 42145, 21193-21199, 21206 and 21685).

Prior authorization is not required for adenoidectomy and tonsillectomy procedures (CPT codes 42820-42821, 42825-42826, 42830-42831 and 42835-42836).

Commercial PPO
Prior authorization is required for sleep apnea surgery, adenoidectomy or tonsillectomy. (CPT codes 42145, 21193-21199, 21206 and 21685).

Prior authorization is not required for adenoidectomy and tonsillectomy procedures (CPT codes 42820-42821, 42825-42826, 42830-42831 and 42835-42836).

Medicare HMO BlueSM Prior authorization is required for sleep apnea surgery (CPT codes 42145, 21193-21199, 21206 and 21685).

Prior authorization is not required for adenoidectomy and tonsillectomy procedures (CPT codes 42820-42821, 42825-42826, 42830-42831 and 42835-42836).

Medicare PPO BlueSM Prior authorization is required for sleep apnea surgery (CPT codes 42145, 21193-21199, 21206 and 21685).

Prior authorization is not required for sleep apnea surgery, adenoidectomy or tonsillectomy procedures (CPT codes 42820- 42821, 42825-42826, 42830-42831 and 42835-42836).

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.
To ensure the service request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources Refer to our Authorization Manager page for tips, guides, and video demonstrations. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member

4

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes: Code Description 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft 21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation 21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation 21198 Osteotomy, mandible, segmental 21199 Osteotomy, mandible, segmental; with genioglossus advancement 21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) 21685 Hyoid myotomy and suspension 42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) 42820 Tonsillectomy and adenoidectomy; younger than age 12 42821 Tonsillectomy and adenoidectomy; age 12 or over 42825 Tonsillectomy, primary or secondary; younger than age 12 42826 Tonsillectomy, primary or secondary; age 12 or over 42830 Adenoidectomy, primary; younger than age 12 42831 Adenoidectomy, primary; age 12 or over 42835 Adenoidectomy, secondary; younger than age 12 42836 Adenoidectomy, secondary; age 12 or over ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description G47.30 Sleep apnea, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description 0CQ70ZZ Repair Tongue, Open Approach 09QN0ZZ Repair Nasopharynx, Open Approach 09QN3ZZ Repair Nasopharynx, Percutaneous Approach 09QN4ZZ Repair Nasopharynx, Percutaneous Endoscopic Approach 09QN7ZZ Repair Nasopharynx, Via Natural or Artificial Opening 09QN8ZZ Repair Nasopharynx, Via Natural or Artificial Opening Endoscopic 09RN0JZ Replacement of Nasopharynx with Synthetic Substitute, Open Approach 09RN7JZ Replacement of Nasopharynx with Synthetic Substitute, Via Natural or Artificial Opening 09RN8JZ Replacement of Nasopharynx with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic

5

09UN0JZ Supplement Nasopharynx with Synthetic Substitute, Open Approach 09UN7JZ Supplement Nasopharynx with Synthetic Substitute, Via Natural or Artificial Opening 09UN8JZ Supplement Nasopharynx with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0CQ20ZZ Repair Hard Palate, Open Approach 0CQ23ZZ Repair Hard Palate, Percutaneous Approach 0CQ30ZZ Repair Soft Palate, Open Approach 0CQ33ZZ Repair Soft Palate, Percutaneous Approach 0CQ73ZZ Repair Tongue, Percutaneous Approach 0CQ7XZZ Repair Tongue, External Approach 0CQM0ZZ Repair Pharynx, Open Approach 0CQM3ZZ Repair Pharynx, Percutaneous Approach 0CQM4ZZ Repair Pharynx, Percutaneous Endoscopic Approach 0CQM7ZZ Repair Pharynx, Via Natural or Artificial Opening 0CQM8ZZ Repair Pharynx, Via Natural or Artificial Opening Endoscopic 0CQN3ZZ Repair Uvula, Percutaneous Approach 0CQNXZZ Repair Uvula, External Approach 0CS20ZZ Reposition Hard Palate, Open Approach 0CS30ZZ Reposition Soft Palate, Open Approach 0CTP0ZZ Resection of Tonsils, Open Approach 0CTQ0ZZ Resection of Adenoids, Open Approach 0CU207Z Supplement Hard Palate with Autologous Tissue Substitute, Open Approach 0CU20JZ Supplement Hard Palate with Synthetic Substitute, Open Approach 0CU20KZ Supplement Hard Palate with Nonautologous Tissue Substitute, Open Approach 0CU237Z Supplement Hard Palate with Autologous Tissue Substitute, Percutaneous Approach 0CU23JZ Supplement Hard Palate with Synthetic Substitute, Percutaneous Approach 0CU23KZ Supplement Hard Palate with Nonautologous Tissue Substitute, Percutaneous Approach 0CU307Z Supplement Soft Palate with Autologous Tissue Substitute, Open Approach 0CU30JZ Supplement Soft Palate with Synthetic Substitute, Open Approach 0CU30KZ Supplement Soft Palate with Nonautologous Tissue Substitute, Open Approach 0CU337Z Supplement Soft Palate with Autologous Tissue Substitute, Percutaneous Approach 0CU33JZ Supplement Soft Palate with Synthetic Substitute, Percutaneous Approach 0CU33KZ Supplement Soft Palate with Nonautologous Tissue Substitute, Percutaneous Approach 0CUM07Z Supplement Pharynx with Autologous Tissue Substitute, Open Approach 0CUM0JZ Supplement Pharynx with Synthetic Substitute, Open Approach 0CUM0KZ Supplement Pharynx with Nonautologous Tissue Substitute, Open Approach 0CUM77Z Supplement Pharynx with Autologous Tissue Substitute, Via Natural or Artificial Opening 0CUM7JZ Supplement Pharynx with Synthetic Substitute, Via Natural or Artificial Opening 0CUM7KZ Supplement Pharynx with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0CUM87Z Supplement Pharynx with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0CUM8JZ Supplement Pharynx with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0CUM8KZ Supplement Pharynx with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0NQT0ZZ Repair Right Mandible, Open Approach 0NQT3ZZ Repair Right Mandible, Percutaneous Approach 0NQT4ZZ Repair Right Mandible, Percutaneous Endoscopic Approach 0NQTXZZ Repair Right Mandible, External Approach

6

0NQV0ZZ Repair Left Mandible, Open Approach 0NQV3ZZ Repair Left Mandible, Percutaneous Approach 0NQV4ZZ Repair Left Mandible, Percutaneous Endoscopic Approach 0NQVXZZ Repair Left Mandible, External Approach 0NUT07Z Supplement Right Mandible with Autologous Tissue Substitute, Open Approach 0NUT0JZ Supplement Right Mandible with Synthetic Substitute, Open Approach 0NUT0KZ Supplement Right Mandible with Nonautologous Tissue Substitute, Open Approach 0NUT37Z Supplement Right Mandible with Autologous Tissue Substitute, Percutaneous Approach 0NUT3JZ Supplement Right Mandible with Synthetic Substitute, Percutaneous Approach 0NUT3KZ Supplement Right Mandible with Nonautologous Tissue Substitute, Percutaneous Approach 0NUT47Z Supplement Right Mandible with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUT4JZ Supplement Right Mandible with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUT4KZ Supplement Right Mandible with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUV0JZ Supplement Left Mandible with Synthetic Substitute, Open Approach 0NUV0KZ Supplement Left Mandible with Nonautologous Tissue Substitute, Open Approach 0NUV3JZ Supplement Left Mandible with Synthetic Substitute, Percutaneous Approach 0NUV3KZ Supplement Left Mandible with Nonautologous Tissue Substitute, Percutaneous Approach 0NUV4JZ Supplement Left Mandible with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUV4KZ Supplement Left Mandible with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach

The following CPT and HCPCS codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes: Code Description 41512 Tongue base suspension, permanent suture technique 41530 Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session 0978T Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil 0979T Submucosal cryolysis therapy; soft palate only 0980T Submucosal cryolysis therapy; base of tongue and lingual tonsil only HCPCS Codes HCPCS codes: Code Description A7047 Oral interface used with respiratory suction pump, each 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 S2080

Laser-assisted uvulopalatoplasty (LAUP)

7

According to the policy statement above, the following HCPCS codes are considered investigational for the conditions listed for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: HCPCS Codes HCPCS codes: Code Description E0600 Respiratory suction pump, home model, portable or stationary, electric A7002 Tubing, used with suction pump, each 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

Description Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is characterized by repetitive episodes of upper airway obstruction due to the collapse and obstruction of the upper airway during sleep. The hallmark symptom of OSA is excessive daytime sleepiness, and the typical clinical sign of OSA is snoring, which can abruptly cease and be followed by gasping associated with a brief arousal from sleep. The snoring resumes when the patient falls back to sleep, and the cycle of snoring/apnea/arousal may be repeated as frequently as every minute throughout the night. Sleep fragmentation associated with the repeated arousal during sleep can impair daytime activity. For example, adults with OSA-associated daytime somnolence are thought to be at higher risk for accidents involving motorized vehicles (ie, cars, trucks, heavy equipment). OSA in children may result in neurocognitive impairment and behavioral problems. In addition, OSA affects the cardiovascular and pulmonary systems. For example, apnea leads to periods of hypoxia, alveolar hypoventilation, hypercapnia, and acidosis. This, in turn, can cause systemic hypertension, cardiac arrhythmias, and cor pulmonale. Systemic hypertension is common in individuals with OSA. Severe OSA is associated with decreased survival, presumably related to severe hypoxemia, hypertension, or an increase in automobile accidents related to overwhelming sleepiness.

There are racial and ethnic health disparities seen for OSA, impacting the prevalence of disease and accessibility to treatment options, particularly affecting children. Black children are 4 to 6 times more likely to have OSA than White children.1, Among young adults 26 years of age or younger, African American individuals are 88% more likely to have OSA compared to White individuals. Another study found that African American individuals 65 years of age and older were 2.1 times more likely to have severe OSA than White individuals of the same age group. These health disparities may affect accessibility to treatment for OSA and impact health outcomes. One analysis of insurance claims data, including over 500,000 patients with a diagnosis of OSA, found that increased age above the 18- to 29- year range (p<.001) and Black race (p=.020) were independently associated with a decreased likelihood of receiving surgery for sleep apnea.2, Lee et al (2022) found that Black men had a continuous mortality increase specifically related to OSA over the study period (1999 to 2019; annual percentage change 2.7%; 95% confidence interval, 1.2 to 4.2) compared to any other racial group.3,

Terminology and diagnostic criteria for OSA are shown in Table 1

Table 1. Terminology and Definitions for Obstructive Sleep Apnea Terms Definitions Respiratory Event Apnea The frequency of apneas and hypopneas is measured from channels assessing oxygen desaturation, respiratory airflow, and respiratory effort. In adults, apnea is defined as a drop in airflow by ≥90% of pre-event baseline for at least 10 seconds.

8

Terms Definitions Respiratory Event Due to faster respiratory rates in children, pediatric scoring criteria define an apnea as ≥2 missed breaths, regardless of its duration in seconds. Hypopnea Hypopnea in adults is scored when the peak airflow drops by at least 30% of pre- event baseline for at least 10 seconds in association with either at least 4% arterial oxygen desaturation or an arousal. Hypopneas in children are scored by a ≥50% drop in nasal pressure and either a ≥3% decrease in oxygen saturation or an associated arousal. RERA Respiratory event-related arousal is defined as an event lasting at least 10 seconds associated with flattening of the nasal pressure waveform and/or evidence of increasing respiratory effort, terminating in an arousal but not otherwise meeting criteria for apnea or hypopnea Respiratory event reporting Apnea/Hypopnea Index (AHI) The average number of apneas or hypopneas per hour of sleep Respiratory Disturbance Index (RDI) The respiratory disturbance index is the number of apneas, hypopneas, or respiratory event-related arousals per hour of sleep time. RDI is often used synonymously with the AHI. Respiratory event index (REI) The respiratory event index is the number of events per hour of monitoring time. Used as an alternative to AHI or RDI in home sleep studies when actual sleep time from EEG is not available. Diagnosis Obstructive sleep apnea (OSA) Repetitive episodes of upper airway obstruction due to the collapse and obstruction of the upper airway during sleep Mild OSA In adults: AHI of 5 to <15. In children: AHI ≥1 to 5 Moderate OSA AHI of 15 to < 30. Children: AHI of > 5 to 10 Severe OSA Adults: AHI ≥30. Children: AHI of >10 Treatment Positive airway pressure (PAP) Positive airway pressure may be continuous (CPAP) or auto-adjusting (APAP) or Bi- level (Bi-PAP). PAP Failure Usually defined as an AHI greater than 20 events per hour while using PAP PAP Intolerance PAP use for less than 4 h per night for 5 nights or more per week, or refusal to use CPAP. CPAP intolerance may be observed in individuals with mild, moderate, or severe OSA OSA: obstructive sleep apnea; PSG: Polysomnographic

Summary Description Obstructive sleep apnea (OSA) syndrome is characterized by repetitive episodes of upper airway obstruction due to the collapse of the upper airway during sleep. For individuals who have failed conservative therapy, established surgical approaches may be indicated. This evidence review addresses minimally invasive surgical procedures for the treatment of OSA. They include laser-assisted uvuloplasty, tongue base suspension, radiofrequency volumetric reduction of palatal tissues and base of tongue, palatal stiffening procedures, and hypoglossal nerve stimulation (HNS). This evidence review does not

9

address conventional surgical procedures such as uvulopalatopharyngoplasty (UPPP), hyoid suspension, surgical modification of the tongue, maxillofacial surgery, or adenotonsillectomy. Summary of Evidence For individuals who have obstructive sleep apnea (OSA) who receive laser-assisted uvulopalatoplasty (LAUP), the evidence includes 2 systematic reviews and randomized controlled trials (RCT). Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A 2019 systematic review involving 3,093 patients across 42 studies (4 RCTs) to assess complications of LAUP for snoring and OSA identified the most frequent complications being globus sensation (8%), dryness (7%), and velopharyngeal (VP) insufficiency (4%), with globus and VP insufficiency occurring significantly more than in the general or post-oropharyngeal surgery populations (relative risks: 1.48 and 2.25, respectively). On average, 26 complications were seen per 100 LAUP-treated patients, and pain lasted around 12 days. A earlier meta-analysis of 23 studies (717 adults) on LAUP for OSA, found an AHI mean decrease of 6.56 events/h, but only a 23% success rate and 8% cure rate; 44% of patients experienced worsening AHI, with minimal improvement in lowest O2 saturation. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have OSA who receive radiofrequency volumetric reduction of palatal tissues and base of tongue, the evidence includes 2 sham-controlled randomized trials and a prospective, single-arm cohort study. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment- related morbidity. Single-stage radiofrequency to palatal tissues did not improve outcomes compared with sham. Multiple sessions of radiofrequency to the palate and base of tongue did not significantly (statistically or clinically) improve AHI, and the improvement in functional outcomes was not clinically significant. The prospective cohort study included 56 patients with mild-to-moderate OSA who received 3 sessions of office-based multilevel RFA. Results demonstrated improvement in AHI and Oxygen Desaturation Index (ODI) at the 6-month follow up. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have OSA who receive palatal stiffening procedures, the evidence includes 2 sham- controlled randomized trials and several case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The 2 RCTs differed in their inclusion criteria, with the study that excluded patients with Friedman tongue position of IV and palate of 3.5 cm or longer reporting greater improvement in AHI (45% success) and snoring (change of -4.7 on a 10-point visual analog scale) than the second trial. Additional studies are needed to corroborate the results of the more successful trial and, if successful, define the appropriate selection criteria. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have OSA who receive tongue base suspension, the evidence includes a feasibility RCT with 17 patients. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The single RCT compared tongue suspension plus UPPP with tongue advancement plus uvulopalatopharyngoplasty (UPPP) and showed success rates of 50% to 57% for both procedures. Additional RCTs with a larger number of subjects are needed to determine whether tongue suspension alone or added to UPPP improves the net health outcome. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 2/2026 Annual policy review. Policy updated with literature review through November 17, 2025; references added. 8/2025 Annual policy review. Policy updated with literature review through April 10, 2025; references added. Policy statements unchanged. 7/2025 Clarified coding information. 1/2024 Clarified coding information. 10/2023 Clarified coding information. 9/2023 Policy clarified to include prior authorization requests using Authorization Manager.

10

8/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2023 AIM Specialty Health changed its name to Carelon Medical Benefits Management. 9/2022 Hypoglossal nerve stimulation for obstructive sleep apnea (OSA) retired from policy

130. Effective 9/11/2022. For coverage information, see AIM Specialty Health Clinical Appropriateness Guidelines for Sleep Disorder Management. Clarified coding information. 8/2022 Annual policy review. References added. Minor editorial refinements to policy statements; intent unchanged. Policy statements unchanged. 6/2022 Prior authorization information clarified for PPO plans. Effective 6/1/2022. 4/2022 Clarified coding information. 1/2022 Clarified coding information and prior authorization table. 11/2021 Annual policy review. New investigational indications described for Non-CPAP Medical Treatment of OSA: Daytime Tongue Stimulation; Daytime sleep study (PAP-NAP); Nasal Expiratory Positive Airway Pressure; eXciteOSA; and NightBalance Sleep Position Trainer. Clarified coding information. Title changed. Effective 11/2021. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
     8/2020 Annual policy review. Description, summary and references updated. Policy statement(s) unchanged. 4/2020 Local Coverage Determination (LCD): Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38387) added. Effective 4/1/2020. 8/2019 Annual policy review. The indication for hypoglossal nerve stimulation was clarified to indicate apnea/hypopnea index of ≥15 for alignment with the Food and Drug Administration-approved indication. 5/2019 Annual policy review. New medically necessary indications described. Hypoglossal nerve stimulation is medically necessary under specified conditions. Clarified coding information. Effective 5/1/2019. 2/2019 Policy statements on adenotonsillectomy in children with obstructive sleep apnea and hypertrophic tonsils revised. Effective 2/1/2019. 6/2018 Clarified coding information. 1/2018 Clarified coding information. 10/2017 New references added from Annual policy review. 5/2017 Annual policy review. Medically necessary policy statement revised to include variants of palatopharyngoplasty. New references added. Effective 5/1/2017. 1/2017 Clarified coding information for the 2017 code changes. 6/2016 Clarified coding information. 10/2014 Annual policy review. New investigational indications described. Coding information clarified. Effective 10/1/2014. 5/2014 Updated Coding section with ICD10 procedure and diagnosis codes. Effective 10/2015. 3/2014 Coding information clarified. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
     12/2010 Annual policy review. Changes made to policy statement.
     9/1/2010 Annual policy review. Changes made to policy statement.
     8/1/2009 Medical Policy 130 developed effective 8/1/2009. 5/2008 Updated to clarify coverage exclusion of radiofrequency volumetric tissue reduction of the palatal tissues with coblation technology. 2/2008 Annual policy review. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines

11

Clinical Exception Process Medical Technology Assessment Guidelines

References Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

1. Dudley KA, Patel SR. Disparities and genetic risk factors in obstructive sleep apnea. Sleep Med. Feb 2016; 18: 96-102. PMID 26428843
2. Cohen SM, Howard JJM, Jin MC, et al. Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea. OTO Open. 2022; 6(1): 2473974X221088870. PMID 35321423
3. Lee YC, Chang KY, Mador MJ. Racial disparity in sleep apnea-related mortality in the United States. Sleep Med. Feb 2022; 90: 204-213. PMID 35202926
4. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Surgical management of sleep apnea. TEC Assessments. 1995;Volume 10:Tab 32.
5. Friedman M, Schalch P, Lin HC, et al. Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. Feb 2008; 138(2): 209-16. PMID 18241718
6. Lee LA, Yu JF, Lo YL, et al. Comparative effects of snoring sound between two minimally invasive surgeries in the treatment of snoring: a randomized controlled trial. PLoS One. 2014; 9(5): e97186. PMID 24816691
7. Patel S, Kon SSC, Nolan CM, et al. The Epworth Sleepiness Scale: Minimum Clinically Important Difference in Obstructive Sleep Apnea. Am J Respir Crit Care Med. Apr 01 2018; 197(7): 961-963. PMID 28961021
8. Ferguson KA, Heighway K, Ruby RR. A randomized trial of laser-assisted uvulopalatoplasty in the treatment of mild obstructive sleep apnea. Am J Respir Crit Care Med. Jan 01 2003; 167(1): 15-9. PMID 12502473
9. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Radiofrequency volumetric tissue reduction for sleep-related breathing disorders. TEC Assessments. 2000;Volume 15:Tab 15.
10. Bäck LJ, Liukko T, Rantanen I, et al. Radiofrequency surgery of the soft palate in the treatment of mild obstructive sleep apnea is not effective as a single-stage procedure: A randomized single- blinded placebo-controlled trial. Laryngoscope. Aug 2009; 119(8): 1621-7. PMID 19504550
11. Woodson BT, Steward DL, Weaver EM, et al. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. Jun 2003; 128(6): 848-61. PMID 12825037
12. Herman H, Stern J, Alessi DM, et al. Office-Based Multilevel Radiofrequency Ablation for Mild-to- Moderate Obstructive Sleep Apnea. OTO Open. 2023; 7(1): e19. PMID 36998558
13. Steward DL, Huntley TC, Woodson BT, et al. Palate implants for obstructive sleep apnea: multi- institution, randomized, placebo-controlled study. Otolaryngol Head Neck Surg. Oct 2008; 139(4): 506-10. PMID 18922335
14. Neruntarat C. Long-term results of palatal implants for obstructive sleep apnea. Eur Arch Otorhinolaryngol. Jul 2011; 268(7): 1077-80. PMID 21298386
15. Maurer JT, Sommer JU, Hein G, et al. Palatal implants in the treatment of obstructive sleep apnea: a randomised, placebo-controlled single-centre trial. Eur Arch Otorhinolaryngol. Jul 2012; 269(7): 1851-
16. PMID 22228439
17. Thomas AJ, Chavoya M, Terris DJ. Preliminary findings from a prospective, randomized trial of two tongue-base surgeries for sleep-disordered breathing. Otolaryngol Head Neck Surg. Nov 2003; 129(5): 539-46. PMID 14595277
18. Costantino A, Rinaldi V, Moffa A, et al. Hypoglossal nerve stimulation long-term clinical outcomes: a systematic review and meta-analysis. Sleep Breath. Jun 2020; 24(2): 399-411. PMID 31418162
19. Steffen A, Sommer JU, Hofauer B, et al. Outcome after one year of upper airway stimulation for obstructive sleep apnea in a multicenter German post-market study. Laryngoscope. Feb 2018; 128(2): 509-515. PMID 28561345
20. Steffen A, Sommer UJ, Maurer JT, et al. Long-term follow-up of the German post-market study for upper airway stimulation for obstructive sleep apnea. Sleep Breath. Sep 2020; 24(3): 979-984. PMID 31485853

12

20. Strollo PJ, Soose RJ, Maurer JT, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. Jan 09 2014; 370(2): 139-49. PMID 24401051
21. Strollo PJ, Gillespie MB, Soose RJ, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: Durability of the Treatment Effect at 18 Months. Sleep. Oct 01 2015; 38(10): 1593-8. PMID 26158895
22. Woodson BT, Strohl KP, Soose RJ, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: 5- Year Outcomes. Otolaryngol Head Neck Surg. Jul 2018; 159(1): 194-202. PMID 29582703
23. Schwartz AR, Jacobowitz O, Eisele DW, et al. Targeted Hypoglossal Nerve Stimulation for Patients With Obstructive Sleep Apnea: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. Jun 01 2023; 149(6): 512-520. PMID 37022679
24. Heiser C, Steffen A, Hofauer B, et al. Effect of Upper Airway Stimulation in Patients with Obstructive Sleep Apnea (EFFECT): A Randomized Controlled Crossover Trial. J Clin Med. Jun 29 2021; 10(13). PMID 34209581
25. Yu JL, Mahmoud A, Thaler ER. Transoral robotic surgery versus upper airway stimulation in select obstructive sleep apnea patients. Laryngoscope. Jan 2019; 129(1): 256-258. PMID 30208225
26. Huntley C, Boon M, Tschopp S, et al. Comparison of Traditional Upper Airway Surgery and Upper Airway Stimulation for Obstructive Sleep Apnea. Ann Otol Rhinol Laryngol. Apr 2021; 130(4): 370-
27. PMID 32862654
28. Mehra R, Steffen A, Heiser C, et al. Upper Airway Stimulation versus Untreated Comparators in Positive Airway Pressure Treatment-Refractory Obstructive Sleep Apnea. Ann Am Thorac Soc. Dec 2020; 17(12): 1610-1619. PMID 32663043
29. Shah J, Russell JO, Waters T, et al. Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: A single institution experience. Am J Otolaryngol. 2018; 39(3): 266-270. PMID 29540289
30. Huntley C, Chou DW, Doghramji K, et al. Comparing Upper Airway Stimulation to Expansion Sphincter Pharyngoplasty: A Single University Experience. Ann Otol Rhinol Laryngol. Jun 2018; 127(6): 379-383. PMID 29707958
31. Woodson BT, Soose RJ, Gillespie MB, et al. Three-Year Outcomes of Cranial Nerve Stimulation for Obstructive Sleep Apnea: The STAR Trial. Otolaryngol Head Neck Surg. Jan 2016; 154(1): 181-8. PMID 26577774
32. Soose RJ, Woodson BT, Gillespie MB, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: Self-Reported Outcomes at 24 Months. J Clin Sleep Med. Jan 2016; 12(1): 43-8. PMID 26235158
33. Woodson BT, Gillespie MB, Soose RJ, et al. Randomized controlled withdrawal study of upper airway stimulation on OSA: short- and long-term effect. Otolaryngol Head Neck Surg. Nov 2014; 151(5): 880-
34. PMID 25205641
35. Kezirian EJ, Goding GS, Malhotra A, et al. Hypoglossal nerve stimulation improves obstructive sleep apnea: 12-month outcomes. J Sleep Res. Feb 2014; 23(1): 77-83. PMID 24033656
36. Gillespie MB, Soose RJ, Woodson BT, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: Patient-Reported Outcomes after 48 Months of Follow-up. Otolaryngol Head Neck Surg. Apr 2017; 156(4): 765-771. PMID 28194999
37. Heiser C, Maurer JT, Hofauer B, et al. Outcomes of Upper Airway Stimulation for Obstructive Sleep Apnea in a Multicenter German Postmarket Study. Otolaryngol Head Neck Surg. Feb 2017; 156(2): 378-384. PMID 28025918
38. Hasselbacher K, Hofauer B, Maurer JT, et al. Patient-reported outcome: results of the multicenter German post-market study. Eur Arch Otorhinolaryngol. Jul 2018; 275(7): 1913-1919. PMID 29808422
39. Liu P, Kong W, Fang C, et al. Hypoglossal nerve stimulation in adolescents with down syndrome and obstructive sleep apnea: A systematic review and meta-analysis. Front Neurol. 2022; 13: 1037926. PMID 36388229
40. Yu PK, Stenerson M, Ishman SL, et al. Evaluation of Upper Airway Stimulation for Adolescents With Down Syndrome and Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. Jun 01 2022; 148(6): 522-528. PMID 35446411
41. Boon M, Huntley C, Steffen A, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry. Otolaryngol Head Neck Surg. Aug 2018; 159(2): 379-385. PMID 29557280
42. Kent DT, Carden KA, Wang L, et al. Evaluation of Hypoglossal Nerve Stimulation Treatment in Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. Nov 01 2019; 145(11): 1044-1052. PMID 31556927

13

41. Thaler E, Schwab R, Maurer J, et al. Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy. Laryngoscope. May 2020; 130(5): 1333-1338. PMID 31520484
42. Huntley C, Steffen A, Doghramji K, et al. Upper Airway Stimulation in Patients With Obstructive Sleep Apnea and an Elevated Body Mass Index: A Multi-institutional Review. Laryngoscope. Oct 2018; 128(10): 2425-2428. PMID 30098035
43. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. Dec 01 2021; 17(12): 2499-2505. PMID 34351848
44. Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. Oct 2010; 33(10): 1408-13. PMID 21061864
45. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. Dec 01 2021; 17(12): 2507-2531. PMID 34351849
46. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. Sep 2012; 130(3): e714-55. PMID 22926176
47. American Academy of Otolaryngology -- Head and Neck Surgery. Position Statement: Surgical Management of Obstructive Sleep Apnea. 2021; https://www.entnet.org/resource/position-statement- surgical-management-of-obstructive-sleep-apnea/. Accessed November 17, 2025.
48. American Academy of Otolaryngology-Head and Neck Surgery. 2021 Position Statement: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (OSA) https://www.entnet.org/resource/position-statement-hypoglossal-nerve-stimulation-for-treatment-of- obstructive-sleep-apnea-osa/. Accessed November 18, 2025.
49. Clinical Issues Committee, American Society for Metabolic & Bariatric Surgery. Peri-operative management of obstructive sleep apnea. 2012; https://asmbs.org/resources/peri-operative- management-of-obstructive-sleep- apnea. Accessed November 20, 2025.
50. de Raaff CAL, Gorter-Stam MAW, de Vries N, et al. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis. Jul 2017; 13(7): 1095-1109. PMID 28666588
51. National Institute for Health and Care Excellence. Hypoglossal nerve stimulation for moderate to severe obstructive sleep apnoea (IPG598). 2017. https://www.nice.org.uk/guidance/ipg598/chapter/1- Recommendations. Accessed November 21, 2025.
52. Centers for Medicare & Medicaid Services. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N). 2001; https://www.cms.gov/medicare-coverage- database/details/nca-decision- memo.aspx?NCAId=19&ver=7&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy +for+Obstr uctive+Sleep+Apnea+(OSA)&TAId=50&bc=AAAAAAAAEAAA&. Accessed November 19,

53. Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

54. Krakow B, Ulibarri V, Melendrez D, et al. A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP). J Clin Sleep Med. Jun 15 2008; 4(3): 212-22. PMID 18595433
55. Ulibarri VA, Krakow B, McIver ND. The PAP-NAP one decade later: patient risk factors, indications, and clinically relevant emotional and motivational influences on PAP use. Sleep Breath. Dec 2020; 24(4): 1427-1440. PMID 31898192
56. Berry RB, Kryger MH, Massie CA. A novel nasal expiratory positive airway pressure (EPAP) device for the treatment of obstructive sleep apnea: a randomized controlled trial. Sleep. Apr 01 2011; 34(4): 479-85. PMID 21461326
57. Kryger MH, Berry RB, Massie CA. Long-term use of a nasal expiratory positive airway pressure (EPAP) device as a treatment for obstructive sleep apnea (OSA). J Clin Sleep Med. Oct 15 2011; 7(5): 449-53B. PMID 22003339
58. Riaz M, Certal V, Nigam G, et al. Nasal Expiratory Positive Airway Pressure Devices (Provent) for OSA: A Systematic Review and Meta-Analysis. Sleep Disord. 2015; 2015: 734798. PMID 26798519
59. Kureshi SA, Gallagher PR, McDonough JM, et al. Pilot study of nasal expiratory positive airway pressure devices for the treatment of childhood obstructive sleep apnea syndrome. J Clin Sleep Med. Jun 15 2014; 10(6): 663-9. PMID 24932147

14

7. Lai V, Tong BK, Tran C, et al. Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity. Sleep. Aug 01 2019; 42(8). PMID 31180512
8. Kotecha B, Wong PY, Zhang H, et al. A novel intraoral neuromuscular stimulation device for treating sleep-disordered breathing. Sleep Breath. Mar 26 2021. PMID 33772397
9. Baptista PM, Martinez Ruiz de Apodaca P, Carrasco M, et al. Daytime Neuromuscular Electrical Therapy of Tongue Muscles in Improving Snoring in Individuals with Primary Snoring and Mild Obstructive Sleep Apnea. J Clin Med. Apr 27 2021; 10(9). PMID 33925376
10. Srijithesh PR, Aghoram R, Goel A, et al. Positional therapy for obstructive sleep apnoea. Cochrane Database Syst Rev. May 01 2019; 5: CD010990. PMID 31041813
11. Eijsvogel MM, Ubbink R, Dekker J, et al. Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome. J Clin Sleep Med. Jan 15 2015; 11(2): 139-47. PMID 25515276
12. de Ruiter MHT, Benoist LBL, de Vries N, et al. Durability of treatment effects of the Sleep Position Trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial. Sleep Breath. May 2018; 22(2): 441-450. PMID 28913630
13. Berry RB, Uhles ML, Abaluck BK, et al. NightBalance Sleep Position Treatment Device Versus Auto- Adjusting Positive Airway Pressure for Treatment of Positional Obstructive Sleep Apnea. J Clin Sleep Med. Jul 15 2019; 15(7): 947-956. PMID 31383231
14. van Maanen JP, de Vries N. Long-term effectiveness and compliance of positional therapy with the sleep position trainer in the treatment of positional obstructive sleep apnea syndrome. Sleep. Jul 01 2014; 37(7): 1209-15. PMID 25061249
15. Beyers J, Dieltjens M, Kastoer C, et al. Evaluation of a Trial Period With a Sleep Position Trainer in Patients With Positional Sleep Apnea. J Clin Sleep Med. Apr 15 2018; 14(4): 575-583. PMID 29609712
16. Buyse B, Ciordas S, Hoet F, et al. Positional obstructive sleep apnoea: challenging findings in consecutive patients treated with a vibrating position trainer. Acta Clin Belg. Dec 2019; 74(6): 405-

17. PMID 30433857

    Endnotes

    1 Based on expert opinion and the American Academy of Otolaryngology - Head and Neck Surgery Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children. Ootolaryngology Head Neck Surg. 2011 Jul;145.