EmblemHealthCommercial Clinical Policy

Obstructive Sleep Apnea Diagnosis and Treatment Form

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Obstructive Sleep Apnea Diagnosis and Treatment

Indications

(10001) Is the procedure being requested vagus nerve stimulation? 
(20001) Is vagus nerve stimulation being requested? 
(20002) Is the request for treatment purposes? 
(30001) Is vagus nerve stimulation considered investigational according to the policy? 
(40001) Is the procedure being requested radiofrequency tissue-volume reduction somnoplasty? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



Obstructive Sleep Apnea Diagnosis and Treatment for diagnosing sleep disorders Added vagus nerve stimulation to list of investigational procedures for treatment EmblemHealth ConnectiCare Nov. 11, 2017
Removed suggestive symptom criteria from Attended (facility-based) sleep study section for members ≥ 19 years of age EmblemHealth ConnectiCare Mar. 17, 2017
Added pediatric PSG criteria EmblemHealth ConnectiCare Aug. 12, 2016
Added coverage criteria for radiofrequency tissue-volume reduction somnoplasty (Medicaid members only) ConnectiCare Jun. 11, 2018 Emblem Health Policy modified for ConnectiCare business rules EmblemHealth ConnectiCare Mar. 11, 2016
Added tonsillectomy (with or without adenoidectomy) to surgical management section

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Page 20 of 20 EmblemHealth

Oct. 9, 2015
Added atrial fibrillation and significant tachyarrhythmia or bradyarrhythmia to list of co-morbidities that could degrade accuracy of testing in the attended sleep lab environment EmblemHealth Sept. 11, 2015
Added hypoglossal nerve stimulators to list of investigational procedures

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