42299
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
7 Active Policies
A56905 — Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)
J05
L34526 — Surgical Treatment of Obstructive Sleep Apnea (OSA)
J05
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
Related Codes
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