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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.

Prior authorization is required for uvulectomy when requested as a stand-alone procedure for one of the non-covered indications listed below.

Coverage

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

Indications that are covered

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

  1. The member has been diagnosed with obstructive sleep apnea (OSA) by a Sleep Specialist following home sleep study or polysomnogram.
  2. There is demonstrated narrowing or collapse of the retropalatal region (soft palate, uvula, tonsils, and posterior pharyngeal wall).
  3. Clinical documentation indicates that Continuous Positive Airway Pressure (CPAP) therapy has been attempted, but therapy has either failed to achieve adequate treatment response or the member is unable to tolerate CPAP

Requests for coverage of UPPP for treatment of OSA in members younger than 18 years of age will be reviewed by a medical director for determination of medical necessity.

Indications that are not covered

  1. All other uses of UPPP, including treatment of snoring without significant OSA are considered not medically necessary.
  2. Uvulectomy as a stand-alone procedure for treatment of snoring or OSA is considered investigational.

Definitions

Polysomnogram is a test which measures bodily functions during sleep and is done in-lab at a sleep center. It requires a minimum of the following recordings: EEG, EOG, chin EMG, airflow, arterial oxygen saturation, respiratory effort, and ECG or heart rate. Anterior tibialis EMG is useful to assist in detecting movement arousals and may have the added benefit of assessing periodic limb movements, which coexist with sleep related breathing disorders in many individuals.

Sleep specialist is defined as a physician who is Board eligible or certified by the American Board of Sleep Medicine, a pulmonologist or neurologist whose residency/fellowship included specialized training in sleep disorders and whose practice comprises at least 25% of sleep medicine.

Uvula is the fleshy extension at the back of the soft palate that hangs above the throat

Uvulectomy is surgical excision of the uvula

Uvulopalatopharyngoplasty (UPPP) is a surgical procedure in which the airway at the back of the throat is widened by removing excess soft tissue including the uvula, tonsils, and part of the soft palate and pharyngeal area. The goal is 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)

42140

Uvulectomy, excision of the uvula

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. American Academy of Otolaryngology-Head and Neck Surgery (1991). Position Statement: Uuvulopalatopharyngoplasty. Adopted 1991, Reaffirmed 1998, Revised 2010, Reaffirmed 2012. Retrieved from http://www.entnet.org/content/uvulopalatopharyngoplasty
  2. American Academy of Otolaryngology-Head and Neck Surgery (2010). Position Statement: Treatment of Obstructive Sleep Apnea. Adopted 2010, Revised 2012, 2017. Retrieved from http://www.entnet.org/content/treatment-obstructive-sleep-apnea
  3. Aurora, R. N., Casey, K. R., Kristo, D. A., Auebach, S., Bista, S. R., Chowdhuri, S., … 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.
  4. Beninati, W. Treatment of adults with snoring. In: UpToDate, Benca, R (Ed), UpToDate, Waltham, MA. (November 4, 2016)
  5. Garetz S. Adenotonsillectomy for obstructive sleep apnea in children. In: UpToDate, Chervin, R, (Ed), UpToDate, Waltham, MA. (Accessed on December 19, 2016.)
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Sleep Apnea Treatment, Surgical. Lansdale, PA: Hayes, Inc.; Sept, 2005. Reviewed Oct, 2009/Archived Oct, 2011.
  7. Kapur, VK, Auckley, DH, Chowdhuri, S., Kuhlmann,, DC, Mehra, R, Ramar, K Harrrod, C., Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline, Journal of Clinical Sleep Medicine, Vol. 13, No. 3, 2017
  8. Paruthi, S. Management of obstructive sleep apnea in children. In: UpToDate, Chervin, R, (Ed), UpToDate, Waltham, MA. (Accessed on 8/31/2018)
  9. Weaver, E., Vishesh, K. Surgical Treatment of obstructive sleep apnea in adults. In: UpToDate, Collop, N. (Ed), UpToDate, Waltham, MA. (Accessed on 8/31/2018)
  10. Woods, C. Uvulitis: Clinical Features and Treatment. In: UpToDate, Kaplan, S. and Isaacson, G. (Ed), UpToDate, Waltham, MA. (Accessed on Oct 24, 2017.)

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Policy activity

  • 11/27/2012 - Date of origin
  • 10/01/2018 - Effective date
Review date
  • 10/2018
Revision date
  • 10/01/2018

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