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Coverage criteria policies

Uvulopalatopharyngoplasty (UPPP) for Obstructive Sleep Apnea

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea.

Coverage

Coverage for UPPP is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

UPPP is covered for members 18 years of age and older when all the following criteria are met:

  1. Obstructive sleep apnea (OSA) has been diagnosed in a sleep disorders laboratory by a sleep center specialist; and
  2. There is evidence of an anatomical indication (i.e. obstruction); and
  3. Continuous Positive Airway Pressure (CPAP) therapy has been attempted, but therapy has failed to achieve adequate treatment response or patient is unable to tolerate CPAP; and
  4. Discussion between the patient and the sleep specialist has included:
  5. Alternative treatments options; and
  6. The benefits and risks of UPPP surgery.

Indications that are not covered

UPPP is not covered for any additional indication.

Definitions

Sleep Center Specialist includes a physician who is either a diplomate of the American Board of Sleep Medicine (ABSM), Pulmonologist, Neurologist; OR has a Sleep Certification by one of the following Boards: American Board of Internal Medicine (ABIM), American Board of Family Medicine (ABFM), the American Board of Pediatrics (ABP), the American Board of Psychiatry and Neurology (ABPN), or the American Board of Otolaryngology (ABOto).

Uvulopalatopharyngoplasty (UPPP) is the removal of the uvula, part of the palate, pharynx, and tonsils. The purpose of UPPP is to increase the space between the soft palate, tonsils, and pharyngeal wall in order to decrease upper airway resistance, particularly during sleep.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

42145

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Aurora, R. N., Casey, K. R., Kristo, D. A., Auebach, S., Bista, S. R., Chowdhuri, S., Karipot, A., Lamm, C. , Ramar, K. ,Zak, R.,& Morgenthaler, T. (2012). Practice parameters for surgical modifications of the upper airway for obstructive sleep apnea in adults. American Academy of Sleep Medicine. SLEEP, 33(10), 1408-1413. doi: https://www.ncbi.nlm.nih.gov/pubmed/21061864
  2. Hayes, Inc. directory. Sleep Apnea Treatment, Surgical. Lansdale, PA: Hayes, Inc. September, 2005.
  3. ECRI Institute. (2013). Laser-assisted Uvulopalatoplasty for Treating Obstructive Sleep Apnea and Upper Airway Resistance Syndrome. Plymouth Meeting, PA: ECRI Institute.
  4. Beninati, W. Treatment of adults with snoring. In: UpToDate, Benca, R (MD,PhD), UpToDate, Waltham, MA. (November 4, 2016)
  5. Garetz S. Adenotonsillectomy for obstructive sleep apnea in children. In: UpToDate, Chervin, R, (MD, MS), UpToDate, Waltham, MA. (Accessed on December 19, 2016.)
  6. Paruthi, S. Management of obstructive sleep apnea in children. In: UpToDate, Chervin, R, (MD, MS), UpToDate, Waltham, MA. (Accessed on December 19, 2016.)

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Policy activity

  • 11/27/2012 - Date of origin
  • 06/02/2017 - Effective date
Review date
  • 11/2016
Revision date
  • 06/02/2017

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