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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-40000-16

Original Effective Date: 07/15/01

Reviewed: 10/31/17

Revised: 11/15/17

Subject: Medical & Surgical Management of Obstructive Sleep Apnea (OSA), Snoring, and Other Conditions of the Soft Palate and Nasal Passages

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Treatment of obstructive sleep apnea (OSA), an interrupted breathing pattern occurring during sleep, involves both medical and surgical means. This policy addresses various methods for the management of OSA. CPAP, APAP, BiPAP, and Sleep Testing are addressed in separate policies.

Medical management of OSA in adults may include weight loss, avoidance of stimulants, body position adjustment, oral appliances, and use of various types of positive airway pressure therapy (i.e., fixed CPAP, bilevel positive airway pressure [BiPAP], or APAP) during sleep.

Oral appliances can be broadly categorized as mandibular advancing or positioning devices or tongue retaining devices. Oral appliances can either be “off the shelf” or custom made by a dental laboratory or similar provider.

A condition related to OSA has been termed upper airway resistance syndrome (UARS). UARS is characterized by a partial collapse of the airway resulting in increased resistance to airflow. It has been proposed that UARS is a distinct syndrome from OSA that may be considered a disease of arousal.

Surgical Management

Traditional surgeries for OSA or UARS include uvulopalatopharyngoplasty (UPPP) and a variety of maxillofacial surgeries such as mandibular-maxillary advancement (MMA). UPPP involves surgical resection of the mucosa and submucosa of the soft palate, tonsillar fossa, and the lateral aspect of the uvula. The amount of tissue removed is individualized for each patient, as determined by the potential space and width of the tonsillar pillar mucosa between the two palatal arches. UPPP enlarges the oropharynx but cannot correct obstructions in the hypopharynx; thus, patients who fail UPPP may be candidates for additional procedures, depending on the site of obstruction. Additional procedures include hyoid suspensions, maxillary and mandibular osteotomies, or modification of the tongue. Drug-induced sleep endoscopy and/or cephalometric measurements have been used as methods to identify hypopharyngeal obstruction in these patients. The first-line treatment in children is usually adenotonsillectomy.

Several minimally invasive surgical approaches are being evaluated for OSA in adults including:

Laser-Assisted Uvulopalatoplasty (LAUP)-an outpatient procedure proposed as a treatment of snoring with or without associated OSA. In this procedure, superficial palatal tissues are sequentially reshaped using a carbon dioxide laser. The extent of the surgery is typically different from standard UPPP because only part of the uvula and associated soft palate tissues are reshaped. The procedure does not remove or alter tonsils or lateral pharyngeal wall tissues. The patient undergoes from 3 to 7 sessions at 3- to 4-week intervals. One purported advantage of LAUP is that the amount of tissue ablated can be titrated so treatment can be discontinued once snoring is eliminated. LAUP cannot be considered an equivalent procedure to the standard UPPP, with the laser simply representing a surgical tool that the physician may opt to use. LAUP is considered a unique procedure, which raises its own issues of safety and, in particular, effectiveness.

Tongue Base Suspension- the base of the tongue is suspended with a suture that is passed through the tongue and fixated with a screw to the inner side of the mandible, below the tooth roots. The aim of the suspension is to make it less likely for the base of the tongue to prolapse during sleep.

Radiofrequency Ablation of Palatal Tissues and Base of Tongue- similar in concept to LAUP, although a different energy source is used. Radiofrequency is used to produce thermal lesions within the tissues rather than using a laser to ablate the tissue surface, which may be painful. For this reason, radiofrequency ablation appears to be growing in popularity as an alternative to LAUP. In some situations, radiofrequency of the soft palate and base of tongue are performed together as a multilevel procedure.

Palatal stiffening procedures include insertion of palatal implants, injection of a sclerosing agent (snoreplasty), or a cautery-assisted palatal stiffening operation. The operation uses cautery to induce a midline palatal scar designed to stiffen the soft palate to eliminate excessive snoring. The palatal implant device is a cylindrically shaped segment of braided polyester filaments that is permanently implanted submucosally in the soft palate.

Hypoglossal Nerve Stimulation- contracts the genioglossus muscle, the largest upper airway dilator muscle. This causes tongue protrusion and stiffening of the anterior pharyngeal wall, potentially decreasing apneic events. Hypoglossal nerve stimulation systems include an implantable neurostimulator, stimulating leads, and electrodes. Stimulation systems include respiratory sensing leads that permit intermittent stimulation during inspiration. Stimulation parameters are titrated during an in-laboratory polysomnography and can be adjusted by the patient during home use. The device is turned on only during sleep periods.

Atrial overdrive pacing- This approach is being tried because of the bradycardia generally noted during episodes of apnea.

POSITION STATEMENT:

The following procedures or devices meet the definition of medical necessity when the associated criteria are met:

• Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) – in members with clinically significant obstructive sleep apnea (defined in Definition section below) who have failed a trial of continuous positive airway pressure (CPAP) or is contraindicated, the device is prescribed by a treating physician, the device is custom-fitted by qualified dental personnel, AND there is absence of temporomandibular dysfunction or periodontal disease.

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty, relocation pharyngoplasty)- when performed for the treatment of clinically significant obstructive sleep apnea (defined in Definition section below) in appropriately select members who have failed an adequate trial of CPAP OR failed an adequate trial of an oral appliance.

Hyoid suspension, surgical modification of the tongue, or maxillofacial surgery, including mandibular-maxillary advancement (MMA) – in appropriately selected members with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP OR failed an adequate trial of an oral appliance.

Adenotonsillectomy- in pediatric members with clinically significant obstructive sleep apnea (defined in Definition section below) and hypertrophic tonsils.

Surgical treatment of obstructive sleep apnea (OSA) that does not meet the criteria above does not meet the definition of medical necessity.

The following are considered experimental or investigational for the sole or adjunctive treatment of OSA or upper airway resistance syndrome:

• Laser-assisted palatoplasty (LAUP) or radiofrequency volumetric tissue reduction of the palatal tissues

• Tongue base suspension

• Radiofrequency volumetric tissue reduction of the tongue (with or without radiofrequency reduction of the palatal tissues; i.e. Somnoplasty)

• Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent, and the implantation of palatal implants

• Radiofrequency ablation of the nasal passages, soft palate, tonsils, adenoids, or turbinates (i.e. Coblation)

• Atrial overdrive pacing

• Palate and mandible expansion devices

• All other minimally invasive surgical procedures not described above.

There is a lack of clinical data to permit conclusions on net health outcomes.

All devices or interventions, including LAUP, radiofrequency volumetric tissue reduction of the palate, or palatal stiffening procedures, do not meet the definition of medical necessity for the treatment of snoring in the absence of documented OSA; snoring alone is not considered a medical condition.

Implantable hypoglossal nerve stimulators are considered experimental or investigational for all indications, including but not limited to the treatment of OSA. Additional study comparing hypoglossal nerve stimulation to established surgical procedures is needed to permit conclusions on the effect of this treatment on health outcomes. (May be billed with code 64568)

BILLING/CODING INFORMATION:

CPT Coding:

21199

Osteotomy, mandible, segmental; with genioglossus advancement

30801

Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); superficial

30802

Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (i.e., submucosal)

41512

Tongue base suspension, permanent suture technique

41530

Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session (investigational)

42145

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty)

0466T

Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure) (investigational)

0467T

Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator (investigational)

0468T

Removal of chest wall respiratory sensor electrode or electrode array (investigational)

HCPCS Coding:

E0485

Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated fabricated, includes fitting and adjustment

E0486

Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment

S2080

Laser-assisted uvulopalatoplasty (LAUP) (investigational)

ICD-10 Diagnoses Codes That Support Medical Necessity:

G47.30 – G47.39

Sleep apnea

REIMBURSEMENT INFORMATION:

Reimbursement for oral appliances is limited to one (1) in a 12-month period. Services in excess of the limitation are subject to medical review of documentation supporting medical necessity (The following information may be required documentation to support medical necessity: physician history and physical, initial assessment, procedure note, visit note).

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician Initial Assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician procedure note

11505-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) was found at the time of the last guideline revised date.

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date:

• Noncovered Services (L33777)) located at fcso.com.

• Oral Appliances for Obstructive Sleep Apnea (L33611) located at cgsmedicare.com.

DEFINITIONS:

Clinically significant obstructive sleep apnea: defined as those patients meeting any of the following criteria:

1. AHI greater than or equal to 15, OR

2. AHI between 5 and 15 with ANY of the following associated symptoms:

• Excessive daytime sleepiness

• Impaired cognition

• Mood disorders

• Insomnia

• Documented hypertension

• Ischemic heart disease

• History of stroke.

RELATED GUIDELINES:

Sleep Testing, 01-95828-01
Positive Airway Pressure Devices, 09-E0000-21

OTHER:

None applicable.

REFERENCES:

  1. Agency for Healthcare Research and Quality. Comparative Effectiveness of Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. AHRQ Publication No. 11-EHC052-EF. (July, 2011).
  2. Agency for Healthcare Research and Quality. Comparative Effectiveness of Diagnosis and Treatment of Obstructive Sleep Apnea in Adults – Clinician Summary (08/08/2011).
  3. American Academy of Otolaryngology-Head and Neck Surgery. 2016 Position Statement: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (OSA), accessed at entnet.org 09/29/17.
  4. American Academy of Otolaryngology- Head and Neck Surgery. 2016 Position Statement: Tongue Suspension, accessed at entnet.org 09/29/17.
  5. American Academy of Otolaryngology - Head and Neck Surgery. 2012 Position Statement: Uvulopalatopharyngoplasty, accessed at entnet.org 09/29/17.
  6. American Academy of Pediatrics. Tonsillectomy Care for the Pediatrician. Pediatrics Vol. 130 No. 2 August 1, 2012. pp. 324 -334.
  7. American Academy of Sleep Medicine. Fact Sheet for Obstructive Sleep Apnea (2008). Accessed 12/17/12.
  8. American Academy of Sleep Medicine. Littner M, Kushida CA, Hartse K, Anderson WM, Davila D, Johnson SF, Wise MS, Hirshkowitz M, Woodson BT. Practice parameters for the use of laser-assisted uvulopalatoplasty: an update for 2000. [Sleep 2001 Aug 1; 24(5): 603-19].
  9. American Academy of Sleep Medicine. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD, Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009 Jun 15;5(3):263-76.
  10. American Sleep Disorders Association. Aurora RN, Casey KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, Karippot A, Lamm C, Ramar K, Zak R, Morgenthaler TI. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep 2010 Oct 1;33(10):1408-13.
  11. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30.
  12. Blue Cross Blue Shield Association Medical Policy Reference Manual. “Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome” 2.01.18, 07/17.
  13. Blue Cross Blue Shield Association Medical Policy Reference Manual. Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 7.01.101, 09/17.
  14. Blue Cross Blue Shield Association Technology Evaluation Center “Radiofrequency Volumetric Tissue Reduction for Sleep Related Breathing Disorders”, (12/00).
  15. Blue Cross Blue Shield Association Technology Evaluation Center “Surgical Procedures for the Treatment of Obstructive Sleep Apnea Syndrome”, (04/96).
  16. Blue Cross Blue Shield of Florida Technology Assessment Summary “Laser Assisted Uvulopalatoplasty (LAUP)”, (05/29/96).
  17. Carvalho FR, Lentini-Oliveira DA, Machado MAC, Saconato H, Prado LBF, Prado GF. Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005520. DOI: 10.1002/14651858.CD005520.pub2.
  18. CGS Administrators, LLC, Local Coverage Determination (LCD):Oral Appliances for Obstructive Sleep Apnea (L33611) located at cgsmedicare.com.
  19. ClinicalTrials.gov, Effect of Upper Airway Stimulation on Vascular Function in Obstructive Sleep Apnea, sponsored by Emory University, accessed 09/29/17.
  20. ClinicalTrials.gov, Minimally Invasive Hypoglossal Nerve Stimulation Study, sponsored by Medtronic Cardiac Rhythm and Heart Failure, accessed 09/29/17.
  21. ClinicalTrials.gov, A Multicentre, Prospective, Open-label, Non-randomized, Single Arm Treatment Study to Assess the Safety, Performance and Initial Efficacy Trends of the Genio(TM) Bilateral Hypoglossal Nerve Stimulation System for the Treatment of Obstructive Sleep Apnoea, accessed 09/29/17.
  22. ECRI Hotline Article: “Clinical Criteria for Surgical Treatments for obstructive Sleep Apnea”, (10/11/05).
  23. ECRI Hotline Article: “Laser-Assisted Uvulopalatoplasty (LAUP) for Obstructive Sleep Apnea and Upper airway Resistance Syndrome”, 09/15/04).
  24. ECRI Hotline Article: “Palatal Implants for Obstructive Sleep Apnea (OSA)”, 10/21/04).
  25. ECRI Hotline Article: “Radiofrequency Mediated Tongue tissue Reduction (Somnoplasty) for Sleep Apnea”, (08/09/04).
  26. ECRI Hotline Response Article: “Palatal Implants for Obstructive Sleep Apnea (OSA)”, (05/22/06).
  27. ECRI Hotline Response Article: “Radiofrequency Volumetric Tissue Reduction (Somnoplasty) for Obstructive Sleep Apnea or Snoring”, (07/27/06).
  28. ECRI Hotline Response Article. “Radiofrequency Ablation for Treating Obstructive Sleep Apnea or Snoring”, (11/17/2011).
  29. ECRI Hotline Response Article: “Coblation versus Other Surgical Techniques for Tonsillectomy, (03/12/10).
  30. First Coast Service Options, Inc. (FCSO), Local Coverage Determination (LCD): Noncovered Services (L33777) located at fcso.com.
  31. Gillespie MB, Soose RJ, Woodson BT, et al, Upper Airway Stimulation for Obstructive Sleep Apnea: Patient-Reported Outcomes after 48 Months of Follow-up. Otolaryngol Head Neck Surg. 2017 Apr;156(4):765-771.
  32. HAYES Medical Technology Directory. “Radiofrequency Volumetric Tissue Reduction for the Treatment of Upper Airway Obstruction”, (RADI0101.19 – 11/00; updated 10/18/04).
  33. HAYES Medical Technology Directory. “Sleep Apnea Treatment, Devices”, (09/16/99; updated 03/14/05).
  34. HAYES Medical Technology Directory. “Sleep Apnea Treatment, Medical”, (SLEE901.05) (11/28/97; updated 01/21/04).
  35. HAYES Medical Technology Directory. “Sleep Apnea Treatment, Surgical”, (SLEE0602.05) (03/14/05).
  36. Heiser C, Maurer JT, Hofauer B, et al, Outcomes of Upper Airway Stimulation for Obstructive Sleep Apnea in a Multicenter German Postmarket Study. Otolaryngol Head Neck Surg. 2017 Feb;156(2):378-384.
  37. Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.:CD004435. DOI: 10.1002/14651858.CD004435.pub3.
  38. National Institute for Health and Clinical Excellence (NICE). Electrosurgery (diathermy and coblation) for tonsillectomy. Interventional Procedure Guidance 150. London, UK: NICE; December 2005. Accessed 01/27/14.
  39. Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001004. DOI: 10.1002/14651858.CD001004.pub2.
  40. Woodson BT, Soose RJ, Gillespie MB, et al, Three-Year Outcomes of Cranial Nerve Stimulation for Obstructive Sleep Apnea: The STAR Trial. Otolaryngol Head Neck Surg. 2016 Jan;154(1):181-8.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/31/17.

GUIDELINE UPDATE INFORMATION:

05/17/01

MCG reformatted; revised to include information for somnoplasty.

01/01/02

Annual HCPCS coding update: added S2080.

06/15/02

Reviewed; clarification statement added for LAUP vs. laser-assisted UPPP; references updated.

02/15/03

Revised; added information regarding oral orthotic devices for treating OSA.

06/15/03

Reviewed; no changes.

06/15/04

Scheduled review, no revisions.

01/15/05

Annual HCPCS coding update (0088T added).

03/15/05

Scheduled review; no change in coverage statement; add procedure code 0088T.

10/15/05

Revision consisting of adding information regarding palatal stiffening procedures and hyoid suspension.

01/01/06

Annual HCPCS coding update: revise descriptor for 0088T. Add E0485 and E0486.

03/15/06

Scheduled review; no change in coverage statement; remove Program Exception for Medicare Advantage.

04/01/06

2nd Quarter HCPCS coding update: removed S8260.

03/15/07

Scheduled review; added information for atrial pacing; updated references, revised Description section.

06/15/07

Reformatted guideline; updated references.

04/15/08

Scheduled review; no change in position statement; updated ICD-9 coding section and references.

01/01/09

Annual HCPCS coding update: removed 0088T; added 41512 and 41530.

04/15/09

Scheduled review; added position statement regarding somnoplasty; reformatting changes; references updated.

01/01/10

Annual HCPCS coding update: simple revision to descriptor for 41530.

03/15/10

Revision of Position Statement to include additional coverage criteria for UPPP.

10/15/10

Revision; related ICD-10 codes added.

07/15/11

Revision; formatting changes.

03/15/12

Review; position statement revised to include information regarding coblation; references updated.

02/15/13

Review of position statement for Somnoplasty and Coblation; position statement revised for clarification; references updated.

03/15/14

Position statement for coblation reviewed with literature search; no change in position statement; Program Exceptions section updated; references updated.

02/15/15

Revision: added CPT codes 30801 and 30802.

07/30/15

Revision; position statement section and references updated.

11/01/15

Revision: ICD-9 Codes deleted.

02/15/16

Revision; position statement section updated.

11/15/17

Review; description, position statements, coding, program exception, and references updated.

Date Printed: May 27, 2018: 07:39 PM