Sleep Related Breathing Disorders: Surgical Management

This policy covers surgical management of sleep-related breathing disorders—such as palatopharyngoplasty (UPPP and related palatal procedures), hyoid suspension, surgical modification of the tongue, maxillofacial surgery (including mandibular‑maxillary advancement), hypoglossal nerve stimulation (per specified indications), tracheostomy, and related procedures for obstructive sleep apnea (OSA). Coverage is limited to appropriately selected patients (primarily adults and specified adolescents with Down syndrome) with clinically significant OSA who have failed or cannot tolerate CPAP or an oral appliance and who meet objective criteria (e.g., AHI/RDI thresholds, DISE‑documented non‑concentric retropalatal or hypopharyngeal obstruction, BMI limits), while procedures outside FDA indications, those with concentric collapse on DISE, high central apnea proportion, BMI >40 (or >95th percentile in DS adolescents), and numerous minimally invasive or experimental techniques are excluded.