Cigna Oral Appliances for the Treatment of Obstructive Sleep Apnea - (A016) Form

Cigna Medical Coverage Policies

Sleep Disordered Breathing Diagnosis and Treatment Guidelines

PURPOSE Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a conflict, a customer’s benefit plan document always supersedes the information in an .

Coverage determinations require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Administrative Policies and; 4) the specific facts of the particular situation. Administrative Policies relate exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be used as treatment guidelines.

Standard Cigna benefit plans consider an oral appliance to be a covered benefit when medical necessity criteria are met under the Medical Coverage Policy. This policy describes how medically necessary services are reported through CPT/HCPCS and ICD- 10-CM coding.

General Background Custom-fit Oral Appliances - Indications Custom fit oral appliances are indicated when all of the following criteria are met:

• A positive diagnosis of obstructive sleep apnea on a covered sleep study as demonstrated by one of the following:

o apnea-hypopnea index (AHI), respiratory disturbance index (RDI), or respiratory event index (REI) ≥ 5 < 15 events per hour over the duration of the sleep test and documentation of: : A016

 Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia, or  Hypertension, ischemic heart disease, or history of stroke; OR o AHI, RDI, or REI ≥ 15 per hour over the duration of the sleep test. Documentation of:

o o PAP is contraindicated for the individual as documented by the treating physician, or Individual prefers alternative treatment to CPAP (after a discussion of treatment o options with the treating physician) AND AHI, RDI, or REI is < 30. Intolerance or lack of benefit after a minimum of a one-month trial of PAP, or The device is ordered by the treating physician following a face-to-face visit and review of sleep study results.

• A qualified licensed dentist (DDS and DMD) provides a custom device and follow up to assess for dental-related side effect.

Replacement Custom Fit Oral Appliances Custom fit oral appliances can be replaced when all of the following criteria are met:

• Device is being used consistently with continued resolution of symptoms.

• The device is ordered by the treating physician following a face-to-face visit.

• A qualified licensed dentist (DDS and DMD) provides a custom device and follow up to assess for dental-related side effects.

• One of the following applies:

• o Device has been lost or irreparably damaged due to a specific accident, natural disaster or breakdown of device from regular use. o Device is greater than 5 years old.

Pediatric Oral Appliances

Oral appliances may be considered medically necessary in the treatment of children with craniofacial anomalies with signs and symptoms of OSA.