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Coverage criteria policies

Upper airway stimulation – hypoglossal nerve stimulation therapy for obstructive sleep apnea (i.e., Inspire Device)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific 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 not applicable for upper airway stimulation / hypoglossal nerve stimulation therapy for obstructive sleep apnea (OSA) (i.e., Inspire Device) because it is considered investigational/experimental. The provider and facility will be liable for payment unless:

  • The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  • The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  • The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment

Coverage

Upper airway stimulation / hypoglossal nerve stimulation therapy for OSA (i.e., Inspire Device) is considered investigational/experimental and is therefore not covered.

Definitions

Obstructive sleep apnea (OSA) is a result of an obstructed (blocked) airway. The breathing muscles continue to move the chest but, because of the obstruction, air is not able to move in or out of the lungs. OSA is characterized by repeated pauses in breathing during sleep, which lead to the fragmentation of sleep and decreases in the body's oxygen.

Upper airway stimulation (UAS) / hypoglossal nerve stimulation therapy for OSA (i.e., Inspire Device) – the UAS is implanted to give mild electrical stimulation to the hypoglossal nerve, in turn, stimulating the muscles at the base of the tongue and upper airway. This is thought to restore muscle tone and prevent the tongue from falling out of place, which can cause obstructive sleep apnea (OSA).

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

The following codes are not covered when associated with an obstructive sleep apnea diagnosis:

CPT Codes

Codes

Description

64568

Incision for implantation of cranial nerve (e.g. vagus nerve) neurostimulator electrode array and pulse generator

0466T

Insertion of chest wall respiratory sensor

95970

Electronic analysis of implanted neurostimulator pulse generator system

ICD 10 Codes

Codes

Description

G47.30

Sleep apnea, unspecified

G47.33

Obstructive sleep apnea (adult) (pediatric)

G47.39

Other sleep apnea

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 Sleep Medicine-Adult Obstructive Sleep Apnea Task Force (2009). Clinical Guidelines for the Evaluation, Management and Long-Term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine. 2009 Jun 15; 5(3): 263-276.
  2. American College of Physicians- Clinical Guidelines Committee (2013). Management of Obstructive Sleep Apnea in Adults: A Clinical Practive Guideline From the American College of Physicians. Annals of Internal Medicine. 2013; 159(7): 471-483.
  3. Certal, V., Zaghi, S., Riaz, M., Vieira, A., Pinheiro, C., Kushida, C. …Camacho, M. (2015). Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. May;125(5):1254-64. doi: 10.1002/lary.25032. Epub 2014 Nov 12. PMID: 25389029
  4. ECRI Institute. (2018). Inspire Upper Airway Stimulation (Inspire Medical Systems, Inc.) for Treating Obstructive Sleep Apnea. Plymouth Meeting, PA: ECRI Institute.
  5. Hayes, Inc. Health Technology Brief. Hypoglossal Nerve Stimulation (Inspire Upper Airway Stimulation; Inspire Medical Systems Inc.) for Treatment of Obstructive Sleep Apnea. Lansdale, PA: Hayes, Inc. Nov 2014. Reviewed Sept 2015.
  6. Hayes, Inc. Directory. Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea. Lansdale, PA: Hayes, Inc. March, 2016. Reviewed February, 2018.
  7. Kryger, M. and Malhotra, A. Management of Obstructive Sleep Apnea in Adults. In: UpToDate, Collop, N. (Ed), UpToDate, Waltham, MA. (Accessed on 8/25/2017).

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Policy activity

  • 09/09/2015 - Date of origin
  • 09/01/2016 - Effective date
Review date
  • 09/2018

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