Sleep Disordered Breathing Diagnosis and Treatment Form

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Sleep Disordered Breathing Diagnosis and Treatment - Medical Policy
Effective: March 1, 2025 Policy Number:

UM977POL

Approval Date: 12/20/2024

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Obstructive Sleep Apnea (OSA) is a breathing disorder that is defined by episodes of decrease or complete cessation of airflow during sleep. In OSA, airflow is obstructed when the muscles in the back of the throat fail to keep the airway open. Nocturnal respiration in individuals with OSA is characterized by episodes of Apnea (breathing cessation) and Hypopnea (marked reduction in breathing volume). The signs and symptoms of untreated OSA include excessive daytime sleepiness, loud snoring, nocturnal choking, apneas or choking witnessed by bed partner, unrefreshing sleep, morning headaches, reduced libido, and enuresis. Physiological effects of untreated OSA include fluctuating blood oxygen levels, increased heart rate, chronic daytime hypertension and impaired glucose tolerance/insulin resistance.

Diagnosis of OSA as measured by valid testing is defined as:

 The apnea-hypopnea index (AHI), respiratory disturbance index (RDI), respiratory event index (REI) is ≥15 events per hour; or  The AHI, RDI, or REI is ≥5 and <15 events per hour and documentation of: o Symptoms of sleepiness, non-restorative sleep, fatigue, or insomnia OR o Report of awakening with breath-holding, gasping, or choking OR o Bed partner or other observer reports habitual snoring, breathing interruptions, or both during sleep OR o Hypertension, a mood disorder, cognitive dysfunction, coronary artery disease, congestive heart failure, type 2 diabetes mellitus, atrial fibrillation or stroke

OSA severity classification is based on two (2) measures:

 Mild OSA: RDI or AHI 5 to 14 respiratory events per hour of sleep  Moderate OSA: RDI or AHI 15 to 30 respiratory events per hour of sleep  Severe OSA: RDI or AHI greater than 30 respiratory events per hour of sleep

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Medical therapy is considered first line treatment for OSA. Treatment for OSA includes lifestyle modifications (weight loss, avoidance of alcohol or other agents that decrease upper airway patency), positional therapy, positive airway pressure (PAP), oral appliance therapy (OAT), electrostimulation devices, and surgery. PAP therapy may use any one of the following techniques: continuous positive airway pressure (CPAP), automatic positive airway pressure (APAP), bilevel positive airway pressure (BiPAP), variable positive airway pressure (VPAP).

There are a variety of surgical options used to treat OSA. Surgical treatments are considered after failed medical therapy. The intention of surgery is to create a more open airway, so obstructions are less likely to occur.
Implantable hypoglossal nerve stimulation systems are ways to relieve upper airway obstruction. The Inspire® Upper Airway Stimulation device (Inspire Medical) treats moderate-to-severe OSA and is designed for use in individuals who are unable or unwilling to use a CPAP device. Inspire’s construction and implantation are comparable to those of a pacemaker: a surgeon implants the device containing a neurostimulator subcutaneously in the individual’s chest with one lead attached to the individual’s hypoglossal nerve (cranial nerve XII) at the base of the tongue and one lead implanted in the individual’s chest. The lead in the chest consists of a pressure sensor that detects breathing. Information about respiration rate is relayed to the device, which stimulates the hypoglossal nerve in the tongue. When stimulated, the tongue moves forward, thus opening the airway. The individual can operate the device by remote control, which the individual activates before going to sleep. The device turns on after 20 minutes to minimize disrupting the individual’s sleep onset; the device turns off via remote when the individual wakes.

 Line of Business

Commercial:
For the diagnosis of obstructive sleep apnea and sleep disorders HNE has adopted the following InterQual* criteria: CP: Procedures; Sleep Studies and CP: Procedures; Sleep (Pediatrics)

For treatment of sleep apnea please see criteria below

Medicaid – BeHealthy:
For the diagnosis of obstructive sleep apnea and sleep disorders HNE has adopted the following InterQual* criteria: CP: Procedures; Sleep Studies and CP: Procedures; Sleep (Pediatrics) There are no MassHealth guidelines for the diagnosis or treatment of obstructive sleep apnea and sleep disorders.

For treatment of sleep apnea please see criteria below

Medicare:
 For the Diagnosis of obstructive sleep apnea and sleep disorders Health New England follows National Coverage Determination (NCD) 240.4.1, Sleep Testing for Obstructive Sleep Apnea (OSA) found at MCD Search (cms.gov).
 For the surgical treatment or oral appliances for the treatment of sleep apnea or sleep disordered breathing, refer to the applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD) found at MCD Search (cms.gov).
o Surgical Treatment: L34526 Surgical Treatment of Obstructive Sleep Apnea (OSA) o Hypoglossal Nerve Stimulation: L38387, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea o Phrenic nerve stimulator: 160.9, Phrenic Nerve Stimulator o Mandibular advancement oral appliances: LCD L33611, Oral Appliances for Obstructive Sleep Apnea For Approval and authorization for CPAP/BiPaP treatment of sleep disorders for all lines of business Health New England utilizes Northwood Inc.

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Policy

I. Diagnosis of Obstructive Sleep Apnea and Sleep Disorders

A. In HOME sleep studies

1. For individuals > or equal to 18 years of age in home sleep studies do not require a PA.

2. In home sleep studies are considered experimental/investigational in individuals <18 years of age

   B. Initial attended Facility Based Polysomnograms (PSG)

3. For Commercial and Medicare HNE uses InterQual criteria for the diagnosis of sleep apnea:
   a. CP: Procedures; Sleep Studies and CP: Procedures; Sleep (Pediatrics).

4. For Medicare refer to applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD) found at MCD Search (cms.gov) for the diagnosis of sleep apnea

   C. CPAP Titration with Facility-Based Polysomnogram (initial or repeat)

5. For Commercial and Medicare HNE uses InterQual criteria for the diagnosis of sleep apnea:
   a. CP: Procedures; Sleep Studies and CP: Procedures; Sleep (Pediatrics)

6. For Medicare refer to applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD) found at MCD Search (cms.gov) for the diagnosis of sleep apnea

   D. Repeat Facility-Based PSG or Post Home Sleep study.

7. For Commercial and Medicare HNE uses InterQual criteria for the diagnosis of sleep apnea: a. CP: Procedures; Sleep Studies and CP: Procedures; Sleep Pediatrics)

8. For Medicare refer to applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD) found at MCD Search (cms.gov) for the diagnosis of sleep apnea.

   E. Multiple Sleep Latency Testing (MSLT)

9. For Commercial and Medicare HNE uses InterQual criteria for the diagnosis of sleep apnea:
   a. CP: Procedures; Sleep Studies and CP: Procedures; Sleep (Pediatrics)

10. For Medicare refer to applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD) found at MCD Search (cms.gov) for the diagnosis of sleep apnea.

    II. Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS)

    A. Health New England has adopted InterQual criteria for commercial and MassHealth individuals aged 18 and over for the following procedures. For individuals under the age of 18 decisions will be made on a case-by- case basis.

11. Uvulopalatoplasty, uvulopalatopharyngoplasty (Uvulopalatopharyngoplasty (UPPP))
12. Hyoid myotomy and/or suspension, Genioglossal advancement (Osteotomy, Anterior Segment, Mandible)
13. Maxillomandibular advancement (Maxillomandibular Advancement).

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Uvulectomy as stand-alone treatment for OSA is experimental and investigational.

Medicare MEDICAL NECESSITY use the following LCD L34526 Surgical Treatment of Obstructive Sleep Apnea found at https://www.cms.gov/medicare-coverage-database/search.aspx

There are no MassHealth guidelines for the above procedures. The above criteria applies.

B. Hypoglossal Nerve Stimulation for commercial and MassHealth lines of business

1. FDA approved hypoglossal nerve stimulation implantation device is considered medically necessary in adult individuals for the treatment of moderate to severe obstructive sleep apnea when ALL of the following criteria are met for all lines of business except Medicare:

   a. Age 18 years of age or older; and b. Body Mass Index (BMI) is less than 35; and c. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and d. PSG has predominantly obstructive events (defined as central and mixed apneas less than 25% of the total AHI); and e. AHI is 15 to 65 events per hour; and f. 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 or the CPAP has been returned); and g. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy (DISE) procedure; and h. No other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per standardized tonsillar hypertrophy grading scale).

2. FDA approved hypoglossal nerve stimulation implantation device is considered medically necessary in young adults and children for the treatment of obstructive sleep apnea when ALL of the following criteria are met:

   a. Age 13-21; and b. Diagnosis of Downs Syndrome; and c. AHI >10 and <50 with less than 25% central apneas after prior adenotonsillectomy; AND d. Have either tracheotomy or be ineffectively treated with CPAP due to noncompliance, discomfort, undesirable side effects, persistent symptoms despite compliance use, or refusal to use the device; AND e. Body mass index ≤ 95th percentile for age; AND f. Non-concentric retropalatal obstruction on drug-induced sleep endoscopy

   Implantable hypoglossal nerve stimulators are considered INVESTIGATIONAL for all indications other than those listed above.

   The replacement of all or part of an existing hypoglossal nerve stimulator and/or generator is considered medically necessary when the existing hypoglossal nerve stimulator and/or generator is malfunctioning, cannot be repaired, or is no longer under warranty.

   Medicare MEDICAL NECESSITY use the following LCD L38387 Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea found at https://www.cms.gov/medicare-coverage-database/search.aspx

   There are no MassHealth guidelines hypoglossal nerve stimulators. The above criteria applies.

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C. Phrenic nerve stimulator for Commercial and MassHealth lines of business

1. Phrenic nerve stimulator is considered experimental and INVESTIGATIONAL for the treatment obstructive or central sleep apnea for Commercial and MassHealth.

2. For Medicare Advantage HNE follows NCD 160.9, Phrenic Nerve Stimulator found at https://www.cms.gov/medicare-coverage-database/search.aspx

3. There are no MassHealth guidelines for phrenic nerve stimulators. The above criteria applies.

   D. Mandibular advancement oral appliances for Commercial and MassHealth lines of business.

4. Mandibular advancement oral appliances to reduce upper airway collapsibility or tongue retaining devices is considered medically necessary for members who have sleep test results that meets one of the following criteria: a. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events total: OR b. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events total and documentation of any of the following : excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke; OR c. The member has a diagnosis of OSA, and the member is not able to tolerate a positive airway pressure (PAP) device; OR
   d. The member has a diagnosis of OSA and the treating practitioner determines that the use of a PAP device is contraindicated.

5. Replacement of oral appliances is considered medically necessary at the end of 5-years of use. Replacement of these items is considered medically necessary prior to the end of the 5-years due to a change in the member’s condition that results in increase or decrease in severity of OSA or appliance no longer fitting. Replacement needed due to misuse or abuse are not covered.

   For Medicare Advantage HNE follows LCD L33611, Oral Appliances for Obstructive Sleep Apnea found here https://www.cms.gov/medicare-coverage-database/search.aspx

   There are no MassHealth guidelines for mandibular advancement oral appliances. The above criteria applies.

   All follow-up care, including fitting, adjustments, modifications, professional services (not all-inclusive) required during the first 90 days after provision of the oral appliance are considered to be included in the payment for device.

   Oral appliances for snoring (e.g., Slow Wave DS8, and Snore Guard) are considered NOT medically necessary treatment of disease, as snoring is not considered a disease.

   E. For Approval and authorization for CPAP/BiPaP treatment of sleep disorders for all lines of business HNE utilizes Northwood Inc.

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Policy Guidelines and Definitions

Apnea is a cessation of airflow for at least 10 seconds.

Apnea-hypopnea index (AHI) or Respiratory disturbance index (RDI) or Respiratory event index (REI) are defined by the total number of apneas and hypopneas per hour of sleep.

Central Sleep Apnea (CSA) occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations.

Continuous positive airway pressure (CPAP/APAP) is a non-invasive technique for providing single levels of air pressure from a flow generator, via a nose/nose-mouth/whole facemask. The purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in obstructive sleep apnea (OSA.

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

High pretest probability of OSA is defined as having at least one of the following:  Epworth Sleepiness Score >10  Witnessed apnea  Snoring  Gasping and choking  Morning headaches  Bruxism or teeth grinding  Sleep walking  Dream enactment

Polysomnography (PSG) is a test used to diagnosis and assess sleep-disordered breathing that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, airflow, and blood oxygen levels.

Multiple Sleep Latency Test (MSLT) measures the speed of falling asleep. The MSLT is a full-day test that consists of five scheduled naps. After the first nap trial, each nap trial should begin 2 hours after the start of the prior nap trial. This test is always done following a sleep study that measures sleep quality and duration.

Coding Guidance

Diagnosis Code
Description
PA 95800 Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory analysis and sleep time
No 95801 Sleep study, unattended, simultaneous recording of minimum of heart rate, oxygen saturation, respiratory analysis No 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
Yes

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Diagnosis Code
Description
PA 95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) (PA in facility only
No 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate and oxygen saturation, attended by a technologist
Yes 95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
Yes 95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
Yes 95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist
Yes 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
Yes 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
Yes 95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) Not Medically Necessary Yes G0938 Home sleep study test (hst) with type ii portable monitor, unattended; minimum of 7 channels: eeg, eog, emg, ecg/heart rate, airflow, respiratory effort and oxygen saturation No G0399 Home sleep test (hst) with type iii portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ecg/heart rate and 1 oxygen saturation No G0400 Home sleep test (hst) with type iv portable monitor, unattended; minimum of 3 channels No

Treatment (DME is reviewed by Northwood) Procedure Code Description PA Hyoid Myotomy 21121 Genioplasty; sliding osteotomy, single piece Yes 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Yes 21198 Osteotomy, mandible, segmental Yes 21199 Osteotomy, mandible, segmental; with genioglossus advancement Yes 21685 Hyoid myotomy and suspension Yes Maxilloman dibular Advanceme nt 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft Yes 21142 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft Yes 21143 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft Yes 21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) Yes 21146 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) Yes 21147 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining Yes

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autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft Yes 21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) Yes 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Yes 21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation Yes 21198 Osteotomy, mandible, segmental Yes 21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) Yes

Phrenic Nerve Stimulator 33276 Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed Medicare only 33277 Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure) Medicare only 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) Medicare only 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 Medicare only 33280 Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only Medicare only 33281 Repositioning of phrenic nerve stimulator transvenous lead(s) Medicare only 33287 Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator Medicare only 33288 Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) Medicare only 93150 Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming Medicare only 93151 Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system Medicare only 93152 Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography Medicare only 93153 Interrogation without programming of implanted phrenic nerve stimulator system Medicare only *A Phrenic Nerve Stimulator is experimental/investigational for Commercial and MassHealth UPP 42145 Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopalatoplasty) Yes Uvulectomy 42140 Uvulectomy, excision of uvula Yes

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Hypoglossal Nerve Stimulator 64582 Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array Yes 64583 Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator Yes 64584 Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array Yes Mandibular Advanceme nt
Device E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment Yes E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment Yes K1027 Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment E&I No PA K1037 Docking station for use with oral device/appliance used to reduce upper airway collapsibility E&I No PA CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all-inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

American Academy of Sleep Medicine (AASM). Clinical Practice Guideline for Diagnostic Testing of Sleep for Obstructive Sleep Apnea. Published March 15, 2017. Accessed July 25, 2023

American Academy of Sleep Medicine (AASM). Recommended protocols for Multiple Sleep Latency Test and Maintenance of Wakefulness test in adults. Published Dec 1, 2021. Accessed July 25, 2023

American Academy of Sleep Medicine (AASM). Practice Parameters for Respiratory Indications for Polysomnograms in Children Published Dec 10, 2010. Accessed July 25, 2023

Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: A systematic review and meta-analysis. Sleep. 2010;33(10):1396-1407. Certal VF, Zaghi S, Riaz M, et al. Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2015;125(5):1254-1264. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. Kaohsiung J Med Sci. 2020;36(1):7-12 Epstein LJ, Kristo D, Strollo PJ Jr, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276 Ferguson KA, Cartwright R, Rogers R, et al. Oral appliances for snoring and obstructive sleep apnea: A review. Sleep. 2006;29(2):244-262

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UpToDate - Clinical presentation and diagnosis of obstructive sleep apnea in adults. Accessed 7/24/2023.

UpToDate - Evaluation of suspected obstructive sleep apnea in children. Accessed 7/24/2023.

UpToDate – Obstructive Sleep Apnea: Overview of Management in Adults. Accessed 8/30/2023.

UpToDate - Oral appliances in the treatment of obstructive sleep apnea in adults. UpToDate [online serial]. Waltham, MA

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 8/1/2023 Initial Policy Date 12/2023 Added criteria for treatment 1/2024 Added Line of Business section 12/2024 Annual Review effective 3/1/2025.  Criteria for the diagnosis of obstructive sleep apnea and sleep disorders updated to: o InterQual for the Commercial and MassHealth lines of business. o National Coverage Determination for the Medicare line of business.  Clarification changes made to Treatment (Section II).

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be

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mandated by applicable legal requirements of a state, the Federal Government, or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.