61888
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.10
Facility
$403.15
Non-Facility
$403.15
Documentation Required
- The medical record must document that services meet the Coverage Indications, Limitations and/or Medical Necessity sections of LCD L38276, including appropriate use criteria, relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures.
- Patient record must document symptoms, polysomnography reporting, Drug-Induced Sleep Endoscopy (DISE) reporting (CPT 42975), and body mass index (BMI).
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- When using ABN modifier GA on Part A claims, include a signed ABN (Form CMS-R-131) and report occurrence code 32 with the ABN date; an ABN is required if GA is used.
Key Coverage Criteria
- New implantation of a hypoglossal nerve stimulator (HNS) for treatment of obstructive sleep apnea (OSA) is covered when the patient meets the Local Coverage Determination L38276 coverage criteria.
- Revision or replacement of HNS components (electrode, breathing sensor, generator) is medically necessary when the original implantation was performed because the patient met the LCD L38276 coverage criteria.
- Removal of HNS components may be billed using the listed removal codes when clinically indicated (use appropriate CPT codes for removal).
- Predominantly obstructive events defined as central plus mixed apneas comprising less than 25% of total AHI.
- Beneficiary age 22 years or older.
- Body mass index (BMI) less than 35 kg/m2.
15 Active Policies
AMBETTER-CP.MP.180 — Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
AMBETTER-CP.MP.12 — Vagus Nerve Stimulation
AETNA-CPB-0362 — Spasticity Management
AETNA-CPB-0406 — Tinnitus Treatments
AETNA-CPB-0707 — Headaches: Invasive Procedures
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.