0467T
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Report of an appropriate diagnostic polysomnography (PSG) documenting moderate to severe OSA.
- Documentation of CPAP failure, intolerance, or inability to use CPAP.
- Current age and recorded body mass index (BMI).
- Objective upper airway evaluation results demonstrating suitability for hypoglossal nerve stimulation.
Key Coverage Criteria
- Moderate to severe obstructive sleep apnea (OSA) in patients who have failed continuous positive airway pressure (CPAP).
- Patients who meet required objective testing and evaluation, including appropriate polysomnography (PSG), acceptable age and body mass index (BMI), and objective upper airway evaluation measures.
- Use of the Inspire® Upper Airway Stimulation System for treatment of moderate to severe obstructive sleep apnea (OSA).
- Age ≥ 22 years at time of implant consultation.
- Apnea-hypopnea index (AHI) ≥ 15 and ≤ 100 on polysomnography (PSG).
- Body mass index (BMI) ≤ 40 kg/m².
1 Active Policy
AMBETTER-CP.MP.180 — Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
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