Point32Commercial Clinical Policy

Point32 Surgical Procedures for the Treatment of Obstructive Sleep Apnea Form


Maxillomandibular Advancement (MMA)

Indications

(386649) Has the patient been diagnosed with moderate to severe OSA (AHI/RDI > 15) as confirmed by polysomnography or home sleep study? 
(386650) Has the patient been diagnosed with symptomatic mild OSA (AHI/RDI 5-14) along with an Epworth Sleepiness Scale score > 9, excessive daytime sleepiness, impaired cognition, mood disorder, insomnia, hypertension, ischemic heart disease, or history of stroke? 
(386651) Is there documentation of failure of prior medical treatment for OSA, including PAP device trial failure or intolerance, with efforts to resolve these issues? 
(386652) Has the patient been informed of the use of an oral appliance as an alternative to surgery for treatment of OSA? 
(386653) Does documentation confirm craniofacial skeletal abnormalities for which correction is expected to significantly improve OSA? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

08/01/2023

Last Reviewed

NA

Original Document

  Reference



HPHC Medical Policy

6741297
Page 5 of 6
Surgical Procedures for the Treatment of Obstructive Sleep Apnea
VA01AUG23P
VA01AUG23P

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

  1. Strollo PJ Jr, Soose RJ, Maurer JT, et al. for the STAR Trial Group. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014 Jan 9; 370 (2):139-49
  2. U.S. Food and Drug Administration (FDA) Premarket Approval (PMA) for the Inspire II Upper Airway Stimulator.Supplemental order SO21.
  3. Hayes A TractManager Company. Hypoglossal Nerve Stimulation for the Treatment of Obstructive Nerve Stimulation. Health Technology Assessment. October 30, 2018. Annual Review October 25, 2019. Last accessed August 17, 2020 at evidence.hayesinc.com/report/dir.hypoglossal2981.
  4. Patil SP, Ayappa IA, et. Al. Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2019;15(2):335–343.
  5. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017; 13 (3):479–504.
  6. Woodson BT, Strohl KP, Soose RJ, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes. Otolaryngol Head Neck Surg. 2018 Jul; 159 (1):194-202.
  7. Heiser C, Steffen A, Boon M, et al. Post-approval upper airway stimulation predictors of treatment effectiveness in the ADHERE registry. Eur Respir J 2019; 53: 1801405.
  8. Withrow K, Evans S, et.al. Upper Airway Stimulation Response in Older Adults with Moderate to Severe Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2019; 1-6.
  9. Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD) for Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38387). Last accessed on August 17, 2021 at cms.gov/medicare-coverage.Summary of Changes

Summary of Changes

DateChanges
6/23Annual review; no changes
9/22Criteria and coding updated for Integration with Tufts Health Plan (THP)
7/22Annual review; no changes
7/21Annual review; no changes
7/20InterQual criteria adopted for Uvulopalatopharyngoplasty; updated criteria and exclusions section
7/19Annual review. No changes.
6/17Policy revised to reflect vendor management
5/17References updated.
2/16Updated references, added coding, minor formatting changes
1/15Enhance language re: documentation requirements for members with BMI >30. Clarify that GA is frequently performed with Maxillomandibular advancement or mandibular advancement.

Changes supported by specialist consultant.

Approved by Medical Policy Committee:
  • 6/21/23
Approved by Clinical Policy Operational Committee:
  • 3/05,
  • 3/06,
  • 3/07,
  • 4/08,
  • 6/09,
  • 6/10,
  • 9/10,
  • 10/11,
  • 10/12,
  • 12/13,
  • 1/15;
  • 2/16;
  • 5/17;
  • 6/17;
  • 7/19;
  • 8/20;
  • 7/21;
  • 8/22;
  • 1/23;
  • 7/23
Policy Effective Date:

08/01/23

Initiated:

1/04

HPHC Medical Policy

Surgical Procedures for the Treatment of Obstructive Sleep Apnea

6741297
Page 6 of 6
VA01AUG23P

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.