21110
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.84
Facility
$674.70
Non-Facility
$872.77
Documentation Required
- If LAUP, Somnoplasty™, Pillar Procedure™/palatal implant, or other non-covered palatal procedures are billed for denial purposes, bill as CPT 42299 (unlisted procedure, palate/uvula) and include the procedure name (e.g., 'LAUP', 'Somnoplasty', 'Pillar Procedure', 'palatal implant') in the electronic narrative field 2400/SV101-7 (CMS-1500 line 19 equivalent).
- Hospital outpatient departments should use HCPCS code C9727 for palatal implant procedures (Pillar Procedure™) when billing; such claims will be denied as not proven effective.
- Billing and coding determinations for surgical OSA treatment are dependent on meeting LCD L34526 medical necessity and coverage documentation requirements.
- Documented diagnosis of obstructive sleep apnea from a certified sleep disorders laboratory (certification body recognized by the American Academy of Sleep Medicine) is required prior to any proposed surgery.
Key Coverage Criteria
- Surgical treatment of obstructive sleep apnea (OSA) is considered for coverage only when it meets the coverage indications, limitations, and medical necessity requirements described in LCD L34526.
- Uvulopalatopharyngoplasty (UPPP) is covered when all of the following are met: OSA diagnosed in a certified sleep disorders laboratory, Respiratory Disturbance Index (RDI) >= 15, failed or cannot tolerate CPAP or other appropriate noninvasive therapy, documented counseling by a physician with recognized training in sleep disorders about benefits and risks, and evidence of retropalatal or combined retropalatal/retrolingual obstruction as the cause of OSA.
- Mandibular Maxillary Osteotomy and Advancement and/or genioglossus advancement (with or without hyoid suspension) is covered when all of the following are met: OSA diagnosed in a certified sleep disorders laboratory, RDI >= 15, failed or cannot tolerate CPAP or other appropriate noninvasive therapy, documented counseling by a physician with recognized training in sleep disorders, and either evidence of retrolingual obstruction or prior failure of UPPP to correct the OSA.
- Tracheostomy is covered for OSA when, in the attending physician's judgment, the condition is unresponsive to other medical or surgical treatments or other treatments would be ineffective or not indicated.
- Surgery to correct discrete anatomic upper airway abnormalities (e.g., enlarged tonsils or enlarged tongue) is covered when medical records adequately document that the abnormality makes a significant contribution to the patient's OSA and the surgery is medically necessary.
- Submucous radiofrequency reduction of hypertrophied turbinates is covered for nasal obstruction due to turbinate hypertrophy when the turbinate hypertrophy significantly contributes to OSA or significantly compromises CPAP therapy.
17 Active Policies
A56905 — Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)
J05
L34526 — Surgical Treatment of Obstructive Sleep Apnea (OSA)
J05
UMR-POL-UMR-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders
SUREST-POL-SUREST-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders
Related Codes
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