CurrentBlue Cross Blue Shield - MassachusettsPolicy 955

Phrenic Nerve Stimulation for Central Sleep Apnea

This policy governs coverage of implantable phrenic nerve stimulation systems for treatment of central sleep apnea for Blue Cross Blue Shield of Massachusetts members across commercial and Medicare products.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyPhrenic Nerve Stimulation for Central Sleep Apnea

Policy CodePolicy 955

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient procedures described in this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage stance

Inpatient requiredPreauthorization

Not coveredOutpatient coverage

Mar 20, 2026Lit. review

remedēFDA device

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Investigational / Not covered

Covered when ALL of the following are met

Investigational stance: The use of phrenic nerve stimulation for central sleep apnea is considered investigational in all situations.

This results in noncoverage for the indication.

For outpatient settings, phrenic nerve stimulation for central sleep apnea is not a covered service for the following products: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM. Providers should expect denials when these outpatient services are billed for members in the listed product types.

The evidence base for phrenic nerve stimulation in central sleep apnea includes a systematic review, one randomized controlled trial with delayed activation design, and observational studies. Although the randomized trial demonstrated significant improvements in sleep metrics and quality-of-life measures at 6 and 12 months for patients after device activation, the available data are limited—particularly regarding use after failure of standard noninvasive therapies.

Because of these limitations, the policy concludes that the evidence is insufficient to determine that phrenic nerve stimulation improves the net health outcome for central sleep apnea; therefore, phrenic nerve stimulation is considered investigational for this indication.

Coding

Investigational CPT CodesCPTNot Covered

33276	Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed.
33277	Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure).
33278	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including pulse generator and lead(s).
33279	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only.
33280	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only.
33281	Repositioning of phrenic nerve stimulator transvenous lead(s).
33287	Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator.
33288	Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s).
93150	Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming.
93151	Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system.

1–10 of 12

1/2

Investigational HCPCS CodesHCPCSNot Covered

C1823

Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required for Inpatient

Precertification/preauthorization is REQUIRED for all products when the procedure is performed inpatient. Failure to obtain the required precertification may result in denial of inpatient coverage or payment.

Applies to all products when the service is performed inpatient.

Note

Role After Failure of Non‑Surgical Therapy

An invasive procedure (phrenic nerve stimulation) would typically be considered only after failure of non‑surgical therapies. Non‑surgical treatments include positive airway pressure devices (the current standard of care) and respiratory stimulant medications. Documentation should show that these non‑surgical treatments were tried and failed or were not tolerated before considering implantation.

Document prior trials of positive airway pressure therapy and any respiratory stimulant medications, including duration and reasons for failure or intolerance.
If implantation is being requested for an outpatient setting, note that outpatient phrenic nerve stimulation is not a covered service for Commercial Managed Care, Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM per the policy.
Inpatient precertification is still required if the procedure is performed inpatient.

Documentation Required

Coding and Documentation Guidance

Report all services using current industry-standard CPT, HCPCS, and diagnosis codes, and include supporting documentation of prior non‑surgical treatments and reasons for failure or intolerance. Inclusion of a code in policy does not guarantee coverage; verify member contract benefits.

Include operative notes, device implantation details, and activation timing (activation typically delayed ~1 month after implantation).
If precertification was obtained, include the authorization number in claims documentation.

Background

Central sleep apnea (CSA) is characterized by diminished or absent respiratory effort during sleep and may be idiopathic or secondary to conditions such as heart failure, stroke, drug effects, or high-altitude breathing. First-line management typically relies on positive airway pressure therapies (continuous or bilevel PAP) and, when appropriate, supplemental oxygen or respiratory stimulants depending on etiology.

Phrenic nerve stimulation (PNS) is an implantable, battery-powered neurostimulation system that delivers signals to the phrenic nerve to activate the diaphragm and restore more normal breathing patterns during sleep. The investigational therapy evaluated in the literature involves device implantation with activation delayed (commonly 1 month) to allow lead healing; randomized and observational studies report improvements in sleep metrics and quality-of-life measures after activation, but additional evidence is needed to define its role relative to established noninvasive treatments.

Definitions

Central sleep apnea (CSA) definition

DefinitionSleep-disordered breathing due to diminished or absent respiratory effort with repetitive cessation or decrease in both airflow and ventilatory effort during sleep; may be idiopathic or secondary to conditions such as heart failure, stroke, drugs, or high altitude.

Common associationsApneas with Cheyne–Stokes respiration are common in heart failure or post-stroke patients and account for about half of CSA cases.

EpidemiologyLess common than obstructive sleep apnea; estimated prevalence in adults ≥40 years: CSA ~0.9% vs OSA ~47.6% (Sleep Heart Health Study).

Risk factorsAge >65 years, male sex, history of heart failure, history of stroke, certain medical conditions (eg, acromegaly, renal failure, atrial fibrillation, low cervical tetraplegia, mitochondrial diseases), and opioid use.

Clinical consequencesDifficulty maintaining sleep leading to excessive daytime sleepiness, poor concentration, morning headaches, and increased risk of accidents and injuries.

Phrenic nerve stimulation (PNS) definition

DefinitionAn implantable neurostimulation system that stimulates the phrenic nerve to activate the diaphragm and restore a normal breathing pattern during sleep; intended for patients with central sleep apnea.

FDA-cleared deviceThe remedē System (Zoll Medical) is currently the only FDA‑approved phrenic nerve stimulation device for CSA.

Device componentsBattery-powered pulse generator implanted in the right or left pectoral region with two leads: one to stimulate a phrenic nerve (via left pericardiophrenic or right brachiocephalic vein) and one to sense breathing.

OperationDevice runs an algorithm that automatically activates at night when the patient is in a sleeping position and suspends therapy when the patient sits up; programming adjustments can be made externally.

Implant procedureImplantation is performed by a cardiologist under local anesthesia with the generator placed subcutaneously in the pectoral region.

OpenPayer

Phrenic Nerve Stimulation for Central Sleep Apnea

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions