42140
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
1.66
Facility
$151.97
Non-Facility
$304.95
Documentation Required
- A patient presenting with symptoms of OSA has been seen in a face-to-face evaluation with a qualified physician (MD or DO) trained in sleep medicine or with an Advanced Practice Provider working under the direct supervision of a physician trained in sleep medicine prior to beginning treatment for Oral Appliance Therapy (OAT) (AASM and AADSM, December 2012, AAO-HNS, November 2019). A treating physician (MD or DO) or an Advanced Practice Provider must diagnose OSA and recommend course of treatment (AAO-HNS, November 2019). If PAP therapy results in no therapeutic efficacy or patient intolerance or refusal, documentation from the patient's treating physician (MD or DO) or an Advanced Practice Provider must be supplied (to justify alternative therapies such as OAT or surgery). Removable Oral Appliances must be documented by a sleep study (e.g., Polysomnography or Home Sleep Apnea Testing) demonstrating OSA. Polysomnography (Attended) is required to establish moderate-to-severe OSA for surgical indications (AHI ≥ 15 or RDI ≥ 15) and should be repeated if there has been clinically significant weight loss or gain, changes in cardiovascular disease, or persistent or recurrent symptoms since the last study. For implantable hypoglossal nerve stimulation, drug-induced sleep endoscopy (DISE) documentation confirming absence of a complete blockage or complete concentric collapse of the soft palate is required. For implantable hypoglossal nerve stimulation applicants: documentation of BMI, attended polysomnography demonstrating AHI and proportion of central/mixed apneas, and documentation of prior PAP therapy attempts (failure/intolerance/refusal) must be provided. For adolescent Down syndrome HNS candidates: documentation of attended PSG (AHI ≥ 10 and RDI ≤ 50 as specified), BMI percentile for age (<95th), prior adenotonsillectomy status, documented PAP failure/intolerance despite attempts to improve compliance, absence of tracheostomy during sleep, DISE findings, and documented refusal by patient/caregiver of MMA when indicated. Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews. For removable oral appliances, refer to InterQual® CP: Durable Medical Equipment, Noninvasive Airway Assistive Devices criteria (InterQual criteria referenced for medical necessity clinical coverage). Attended polysomnography (PSG) results showing AHI or Respiratory Disturbance Index (RDI) as applicable (policy history revised to require diagnosis of moderate to severe OSA as determined by Polysomnography (Attended); moderate to severe defined as AHI ≥ 15 or RDI ≥ 15). Repeat polysomnography (Attended) is recommended if there has been clinically significant weight loss or gain, changes in cardiovascular disease, or persistent or recurrent symptoms since the last study. Documentation of inability to use or intolerance/failure of positive airway pressure (PAP) therapy (including attempts to improve compliance) when required by device-specific or surgical‑selection criteria (e.g., candidates for HNS or MMA). For HNS/Inspire: documentation that patient meets device labeling criteria (baseline AHI within approved range, BMI within allowed range per model/expanded indications), absence of complete concentric collapse at the soft palate level (clinical evaluation/DISE), and for pediatric Down syndrome indication: age 13–18, AHI within specified range (≥10 and ≤50), contraindication to or failure of adenotonsillectomy as indicated, and failure or intolerance of PAP despite attempts to improve compliance. For mandibular/maxillomandibular procedures: documentation of severity (e.g., severe OSA), intolerance/unwillingness to adhere to PAP or ineffectiveness of oral appliances when cited as selection criteria. Preoperative and postoperative objective and subjective measures when used in studies or clinical assessment: pre/post PSG, Epworth Sleepiness Scale (ESS), Nasal Obstruction Symptom Evaluation (NOSE) scores, and CT/CBCT imaging as applicable (examples cited in DOME studies and other surgical reports). Clinical documentation supporting anatomic site(s) of obstruction and rationale for chosen surgical approach (e.g., evidence of tongue base/hypopharyngeal obstruction for tongue/base procedures). Record of counseling regarding risks, benefits, and alternative therapies (including CPAP and oral appliances) consistent with informed consent and guideline recommendations. Device‑specific documentation per FDA/labeling and institutional requirements (e.g., for Lunoa, documentation of positional OSA with non‑supine AHI < 20; for eXciteOSA documentation of AHI < 15 and adult age ≥ 18; for Remedē documentation of central sleep apnea diagnosis).
Key Coverage Criteria
- Removable Oral Appliances are proven and medically necessary for treating Obstructive Sleep Apnea (OSA) as documented by a sleep study (e.g., Polysomnography or Home Sleep Apnea Testing). Oral Appliance Therapy (OAT) may be an effective alternative to failed positive airway pressure (PAP) therapy (when documentation of PAP no therapeutic efficacy or patient intolerance or refusal is supplied). [...]
- Inspire Upper Airway Stimulation (UAS) system: adults with baseline AHI originally ≥20 and ≤65; expansions include adults with AHI lower limit ≥15 and baseline upper limit up to 100 and BMI upper limit expanded from 32 to 40 — used in adults who have failed or cannot tolerate PAP and who do not have complete concentric collapse at the soft palate level. [...]
- Lunoa System (NightBalance): indicated for treatment of adults with positional OSA with non‑supine AHI < 20.
- eXciteOSA: removable tongue muscle stimulation device indicated to reduce snoring and mild OSA (AHI < 15) in adults ≥ 18 years.
- Remedē System: implantable phrenic nerve stimulator indicated for treatment of moderate to severe central sleep apnea (CSA) in adults.
- AIRvance (Repose/AIRvance) Tongue Suspension system: intended for anterior tongue base suspension; indicated for treatment of OSA and/or snoring.
5 Active Policies
UHC-POL-obstructive-sleep-apnea-treatment — Obstructive and Central Sleep Apnea Treatment
UMR-POL-UMR-obstructive-sleep-apnea-treatment — Obstructive and Central Sleep Apnea Treatment
SUREST-POL-SUREST-obstructive-sleep-apnea-treatment — Obstructive and Central Sleep Apnea Treatment
CIGNA-0158 — Surgical Treatments for Obstructive Sleep Apnea - (0158)
Related Codes
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