SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Anthem SURG.00129 addresses oral, pharyngeal, and maxillofacial surgery for obstructive sleep apnea (OSA) or snoring, including uvulopalatopharyngoplasty (UPPP), soft-tissue reconstruction, jaw realignment procedures, and hypoglossal nerve stimulation. UPPP is covered as medically necessary only when all policy criteria are met, including documented OSA with AHI/RDI >15 and <40 as a sole procedure, or AHI/RDI 10–15 with qualifying comorbidities (e.g., hypertension, sleep-related arrhythmias, pulmonary hypertension, ischemic heart disease, cognitive/mood disorders, prior stroke, or significant daytime sleepiness), or when part of a planned staged/combined surgery also addressing retrolingual obstruction. UPPP, soft-tissue reconstruction, jaw realignment, and hypoglossal nerve stimulation are not covered when criteria are unmet; surgery for snoring without OSA is never covered, and other surgical treatments for OSA are considered investigational and not medically necessary.