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    v1.0.31
    OpenPayerPolicy UpdatesSleep MedicineArkansas BCBS Inspire Coverage Update | OpenPayer
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    ModifiedArkansas Blue Cross and Blue ShieldPolicy 2015035

    Sleep Apnea, Minimally Invasive Surgical

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    Coverage of hypoglossal nerve stimulation using the FDA-approved Inspire device for adults with obstructive sleep apnea and adolescents or young adults with Down syndrome and obstructive sleep apnea, subject to specified clinical criteria.

    Policy Summary
    PayerArkansas Blue Cross and Blue Shield
    PolicySleep Apnea, Minimally Invasive Surgical
    Policy CodePolicy 2015035
    Change TypeModified
    Effective Date05/15/2026
    Next Review DateN/A
    Key ActionDocument CPAP failure or intolerance for adults seeking coverage.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage criteria were revised for hypoglossal nerve stimulation with the FDA-approved Inspire device in adults with obstructive sleep apnea and in adolescents or young adults with Down syndrome and obstructive sleep apnea.

    The policy explicitly excludes hypoglossal nerve stimulation performed with devices other than the listed Inspire device, including Genio.

    18+Adult eligibility age
    15-100Adult AHI range
    ≤25%Central apnea limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≤35
    Adult BMI limit
    10-18Down syndrome age
    ExcludedOther devices

    Medical Necessity Criteria

    Adult obstructive sleep apnea

    Covered as medically necessary when all of the following criteria are met in adults with obstructive sleep apnea using the FDA-approved Inspire device.

    Adult Inspire hypoglossal nerve stimulation criteria

    • Age: Member is 18 years of age or older.>=18 years
    • AHI and central apneas: AHI is 15-100 with central apneas comprising no more than 25%.AHI 15-100; central apneas <=25%

    • CPAP failure or intolerance

      • Residual AHI criterion: Residual AHI is at least 15.>=15
      • Insufficient CPAP use criterion: Member uses CPAP for less than 4 hours per night or on fewer than 5 nights per week.<4 hours/night or fewer than 5 nights/week
      • CPAP intolerance criterion: Member is unable to tolerate CPAP.
    • Body mass index is no greater than 35 kg/m2.<=35 kg/m2
    • Airway anatomy: There is no complete concentric collapse at the soft palate level.Absent

    Down syndrome with obstructive sleep apnea

    Covered as medically necessary when all of the following criteria are met in adolescents or young adults with Down syndrome and obstructive sleep apnea using the FDA-approved Inspire device.

    Down syndrome Inspire hypoglossal nerve stimulation criteria

    • Age: Member is 10 to 18 years of age.10-18 years
    • Prior adenotonsillectomy and sleep-study criteria: Member has undergone prior adenotonsillectomy, and AHI is greater than 10 and less than 50 with central apneas comprising no more than 25%.AHI >10 and <50; central apneas <=25%

      Prior adenotonsillectomy is required.

    • Tracheotomy or ineffective CPAP treatment

    Hypoglossal nerve stimulation performed with any device other than the listed FDA-approved Inspire device is not covered. This exclusion includes other FDA-approved devices, such as Genio.

    Clinical Thresholds and Eligibility Values

    Adult AHI
    Adult AHI range15-100 events per hour
    Applies toAdults with obstructive sleep apnea
    Coverage requirementAHI must be within this range for the adult Inspire pathway
    Central Apnea Percentage
    Maximum central apnea percentage<=25%
    Adult pathwayCentral apneas must comprise no more than 25% of the AHI
    Down syndrome pathwayCentral apneas must comprise no more than 25% after prior adenotonsillectomy

    Documentation and Coverage Risks

    Documentation Required

    Document Adult CPAP Failure or Intolerance

    For adults, document CPAP failure or inability to tolerate CPAP. CPAP failure requires either a residual AHI of 15 or greater, or documented CPAP use of less than 4 hours per night on fewer than 5 nights per week; inability to tolerate CPAP must also be documented.

    • Residual AHI >= 15
    • CPAP use < 4 hours per night for < 5 nights per week
    • Document inability to tolerate CPAP when applicable
    Documentation Required

    Document Down Syndrome Treatment History

    For members ages 10 to 18 with Down syndrome and OSA, document the required treatment history before requesting coverage.

    • Prior adenotonsillectomy is required
    • Document either tracheotomy or ineffective CPAP treatment due to noncompliance, persistent symptoms despite compliant use, or refusal to use the device

    Unsupported block type: denial_risk

    Treatment Overview

    Hypoglossal nerve stimulation is a surgical treatment for obstructive sleep apnea that stimulates the hypoglossal nerve to improve upper-airway patency during sleep. Coverage is limited to selected patients with clinically significant obstructive sleep apnea who have failed or cannot tolerate CPAP and who meet specified body habitus and airway-anatomy requirements.

    Clinical Definitions

    AHI
    Full termApnea-hypopnea index
    MeasurementExpressed as events per hour
    UseUsed to define the required obstructive sleep apnea severity ranges
    CPAP Failure
    Residual AHI criterionResidual apnea-hypopnea index of at least 15
    Inadequate CPAP useFailure to use CPAP for >=4 hours per night for >=5 nights per week
    Alternative basisInability to tolerate CPAP also meets the adult CPAP failure or intolerance pathway
    Policy Summary
    PayerArkansas Blue Cross and Blue Shield
    PolicySleep Apnea, Minimally Invasive Surgical
    Policy CodePolicy 2015035
    Change TypeModified
    Effective Date05/15/2026
    Next Review DateN/A
    Key ActionDocument CPAP failure or intolerance for adults seeking coverage.
    SourceLink
    On This Page
    Medical Necessity CriteriaClinical Thresholds and Eligibility ValuesDocumentation and Coverage RisksTreatment OverviewClinical Definitions
    Tracheotomy:
    Member has a tracheotomy.

  1. Ineffective CPAP treatment reasons

    • Noncompliance: CPAP treatment is ineffective due to noncompliance.
    • Persistent symptoms remain despite compliant CPAP use.
    • Refusal: Member refuses to use the CPAP device.
  2. Body mass index is no greater than the 95th percentile for age.<=95th percentile for age
  3. Airway anatomy: There is no complete concentric collapse at the soft palate level.Absent
    4. Adult BMI
    Adult BMI limit<=35 kg/m2
    Applies toAdults with obstructive sleep apnea
    Coverage requirementBody mass index must be no greater than 35 kg/m2
    Adult CPAP Use
    Minimum nightly use4 hours per night
    Minimum weekly frequency5 nights per week
    Inadequate useFailure to use CPAP for >=4 hours per night for >=5 nights per week
    Adult Residual AHI
    Residual AHI threshold>=15
    DefinitionResidual apnea-hypopnea index of at least 15
    Use in coverageMeets the residual AHI criterion for adult CPAP failure
    Down Syndrome Pathway Age
    Eligible age range10 to 18 years
    PopulationAdolescents or young adults with Down syndrome and obstructive sleep apnea
    Additional requirementPrior adenotonsillectomy is required
    Down Syndrome Pathway AHI
    Qualifying AHI>10 and <50
    Central apnea limitCentral apneas must comprise <=25%
    TimingCriteria apply after prior adenotonsillectomy
    Down Syndrome Pathway BMI
    BMI limit<=95th percentile for age
    PopulationMembers in the Down syndrome pathway
    Coverage requirementBody mass index must be no greater than the 95th percentile for age
    Denial Risk

    Failure to Meet Clinical Criteria Risks Denial

    Coverage may be denied when any applicable clinical requirement is not met. Verify and document the member's age, AHI range, central-apnea percentage, CPAP treatment history, BMI requirement, airway anatomy, and— for members with Down syndrome—required prior treatment history.

    • Adults: age >= 18; AHI 15-100 with <= 25% central apneas; documented CPAP failure or intolerance; BMI <= 35 kg/m2; and no complete concentric collapse at the soft-palate level
    • Down syndrome pathway: age 10-18; AHI > 10 and < 50 with <= 25% central apneas after prior adenotonsillectomy; tracheotomy or ineffective CPAP treatment; BMI <= 95th percentile for age; and no complete concentric collapse at the soft-palate level
    Complete Concentric Collapse at the Soft Palate Level
    DefinitionCollapse involving the entire circumference of the soft palate
    Coverage requirementComplete concentric collapse at the soft palate level must be absent
    Applies toBoth the adult and Down syndrome Inspire coverage pathways