C8011, Open implantation of hypoglossal nerve(s) neurostimulator electrode array(s)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The policy's definitions for obstructive apnea and hypopnea (duration, reduction criteria, and desaturation threshold) must be used when documenting sleep study results.
- DISE findings (presence or absence of concentric/complete circumferential oropharyngeal collapse) are relevant to hypoglossal nerve stimulation eligibility; concentric collapse is an exclusion.
- Definition of CPAP failure: residual AHI ≥15 while on CPAP, or failure to use CPAP ≥4 hours/night for ≥5 nights/week, or inability to tolerate CPAP — documentation required.
- AHI and RDI definitions as specified in the policy must be used to document event rates for eligibility.
Key Coverage Criteria
- Medically necessary palatopharyngoplasty (various palatal/lateopharyngeal procedures) for adults with clinically significant OSA who have failed CPAP or failed an oral appliance trial.
- Palatopharyngoplasty may be considered medically necessary in adults with clinically significant OSA (AHI/RDI ≥15, or AHI/RDI ≥5 with symptoms) after an adequate trial of CPAP or an oral appliance.
- Hyoid suspension, tongue modification, and/or maxillofacial surgery (including MMA) may be medically necessary for adults with clinically significant OSA and documented hypopharyngeal obstruction who have failed an adequate trial of CPAP or an oral appliance (clinically significant OSA defined as AHI/RDI ≥15 or ≥5 with symptoms).
- Adenotonsillectomy may be medically necessary for pediatric patients with clinically significant OSA and hypertrophic tonsils (pediatric clinically significant OSA: AHI/RDI ≥5 per hour, or AHI/RDI ≥1.5 per hour with daytime sleepiness, behavioral problems, or hyperactivity).
- Hypoglossal nerve stimulation may be medically necessary in adults who meet all of: age ≥18; AHI 15–100 with ≤25% central apneas; documented CPAP failure or inability to tolerate CPAP (residual AHI ≥15 or CPAP use <4 hours/night ≥5 nights/week); BMI ≤40 kg/m²; absence of complete concentric collapse at the soft palate.
- Hypoglossal nerve stimulation may be medically necessary in adolescents (age 13–18) with Down syndrome and OSA who meet all: AHI >10 and <50 with ≤25% central apneas after prior adenotonsillectomy; have tracheotomy or are ineffectively treated with CPAP for listed reasons; BMI ≤95th percentile for age; absence of complete concentric collapse at the soft palate.
4 Active Policies
BCBSIL-SUR706.009, Sleep Related Breathing Disorders: Surgical Management
BCBSMT-SUR706.009, Sleep Related Breathing Disorders: Surgical Management
BCBSNM-SUR706.009, Sleep Related Breathing Disorders: Surgical Management
BCBSOK-SUR706.009, Sleep Related Breathing Disorders: Surgical Management
Related Codes
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