Prior authorization required for hypoglossal nerve stimulation

Hypoglossal nerve stimulation (HNS) is covered only when the patient meets the policy’s specific clinical criteria (age, AHI range, CPAP failure or intolerance, BMI limit, and absence of complete concentric collapse); documentation of these criteria is required before authorization.

• Adults: Age ≥18; AHI ≥15 and ≤100 with ≤25% central apneas; CPAP failure or inability to tolerate CPAP; BMI ≤35 kg/m2; absence of complete concentric collapse.
• Down syndrome adolescents: Age 13–18; AHI >10 and <50 with ≤25% central apneas after adenotonsillectomy; ineffective/untolerated CPAP or tracheotomy; BMI ≤95th percentile; absence of complete concentric collapse.

Investigational procedures / codes — phrenic nerve stimulation not covered

Phrenic nerve stimulation and the listed surgical procedure groups are designated investigational and not covered; claims for investigational services are subject to denial and prior authorization will not establish coverage for investigational interventions.

• Phrenic nerve stimulation for central sleep apnea is labeled investigational (INV) and therefore not covered.
• Surgical treatments for OSA listed as investigational may be noncovered; claims using investigational procedure codes may be denied.

Procedure codes and coverage status — PA may be required

Prior authorization may be required for the surgical and implant procedure codes mapped in the policy; covered surgical treatments and their CPT/HCPCS mappings are listed in the coding table and should be used when requesting authorization.

• Use the policy’s mapping of 21199 and grouped codes (e.g., 42826 group, 64582 group) and note that 64568 may be used to bill the Inspire V Therapy System.
• Confirm covered vs investigational placement in the policy coding table before submission.

Phrenic nerve stimulation coding/coverage change — added as investigational

Phrenic nerve stimulation for central sleep apnea was added as investigational and associated coding was updated; prior authorization processes should follow the investigational/non-covered coding placement in the policy (authorization does not imply coverage for investigational therapies).

• The policy notes addition of INV designation for phrenic nerve stimulation with associated coding changes.
• Providers should not expect coverage when a procedure is designated investigational in the coding table.

Phrenic nerve stimulation (CSA) investigational — not covered

Phrenic nerve stimulation for CSA is explicitly designated investigational (INV) in the policy and therefore not supported for coverage; prior authorization will reflect investigational status and will not confer coverage.

• Remedē System and other phrenic stimulation systems are described in the policy background, but the therapy is listed as investigational in coding/coverage sections.
• Authorization attempts for investigational CSA phrenic nerve stimulation are unlikely to be approved for payment per policy.

HNS prior authorization updates — include AHI ≤100 and pediatric changes

Prior authorization requirements and clinical criteria for HNS were updated — adult criteria now include an upper AHI limit of ≤100 and pediatric criteria were revised (lower age limit and BMI language); prior authorization review must use the revised criteria.

• Adult HNS: AHI ≥15 and ≤100 (with ≤25% central apneas) — include this threshold in PA documentation.
• Pediatric HNS: lower age limit changed to 13 and BMI criteria expressed as percentile-for-age — reflect these revisions in PA requests.

Coding updates and investigational addition — observe updated coding

Phrenic nerve stimulation for CSA was added as investigational and coding was updated; providers should note the investigational coding additions and confirm code placement before submitting authorization or claims.

• Associated investigational coding entries were added to the policy; reference the coding table when preparing submissions.
• Prior authorization for covered procedures should only use codes listed as covered in the current policy.

Prior authorization — coding changes (moved/removed codes)

Certain procedure codes were moved to the non-covered (excluded) coding table and several codes were removed from the policy; prior authorization and billing must reflect the current coding tables to avoid denial.

• Procedure code 41512 has been moved to the non-covered coding table — do not submit expecting coverage.
• Codes removed from the policy include 21299, 31600, 31601, 42870, 42975, and E1399; these should not be used for coverage claims under this policy.

HNS adult AHI threshold updated — use AHI ≤100 in PA review

Adult HNS criteria were revised to add an upper AHI threshold of ≤100; prior authorization review and documentation must reflect this updated AHI eligibility limit.

• Include objective sleep study documentation demonstrating AHI within the 15–100 range when requesting authorization for adult HNS.
• If AHI exceeds 100, HNS is outside the updated eligibility per policy.

Phrenic nerve stimulation for CSA marked investigational — PA/claims at risk

Phrenic nerve stimulation for CSA is repeatedly marked investigational in the policy updates; claims and authorization requests for this therapy are at high risk for denial based on investigational status.

• The policy history and coding tables list phrenic nerve stimulation for CSA as INV — investigational designation implies noncoverage.
• Providers seeking authorization for phrenic nerve stimulation should anticipate denials and may need to supply substantive new evidence for reconsideration.

Coding and prior authorization implications — 41512 moved to non-covered

Procedure code 41512 has been moved to the non-covered coding table in multiple policy entries; do not bill or request authorization expecting coverage when using code 41512.

• Claims billed with CPT 41512 may be denied because it is listed as non-covered in the policy coding table.
• If reconsideration is pursued, documentation must address why an exception is warranted given the policy placement of 41512.

Prior authorization and code coverage changes — phrenic stimulation added as INV; 41512 moved

Phrenic nerve stimulation was added as investigational with associated coding updates and 41512 moved to non-covered; prior authorization expectations should follow the updated coding/coverage designations in the policy.

• Providers should confirm code coverage status before submitting PA requests.
• Investigational designation for phrenic stimulation means PA will not result in standard coverage under this policy.

Prior authorization follows updated coding tables — verify codes

Prior authorization determinations will follow the current coding tables; several codes were moved between covered and non-covered lists or removed from the policy — verify code placement when submitting PAs.

• Claims with removed or non-covered codes may require review or will be denied.
• Use updated coding table in the policy to determine which procedures require PA and which are non-covered.

Prior authorization for HNS — updated adult/pediatric criteria to use in PA

Prior authorization criteria for HNS were revised (adult: added ≤100 AHI; pediatric: age ≥13 and BMI percentile language); PA requests must document compliance with these revised eligibility requirements.

• Include sleep study AHI within updated thresholds and pediatric BMI percentile or age documentation as applicable.
• Document absence of complete concentric collapse (e.g., DISE) where required by policy guidelines.

Prior authorization / code status change — 41512 moved to non-covered

Procedure code 41512 has been moved to the non-covered coding table and related coding expectations updated; prior authorization processes should reflect the non-covered status of 41512.

• Do not expect payment for services billed with CPT 41512 under this policy.
• If using alternative codes for covered procedures, ensure they are listed as covered in the current coding table before authorization.

CPAP first-line before surgery — document prior CPAP/oral appliance trial

Continuous positive airway pressure (CPAP) is the preferred first-line therapy for most patients; surgical options, including HNS, are considered only after an adequate trial of CPAP or an oral appliance has failed or been intolerable.

• Document an adequate trial of CPAP (or oral appliance when appropriate) and evidence of failure/intolerance in any PA request for surgical treatment.
• Policy guidelines explicitly state CPAP is preferred first-line treatment.

Conservative therapy preferred before invasive options — document noninvasive trials

Conservative, noninvasive therapies (e.g., CPAP for hyperventilation-related CSA; supplemental oxygen or bilevel PAP/ASV as appropriate) are preferred before considering invasive procedures; document trials of these therapies prior to PA requests for invasive interventions.

• For CSA, document trials of CPAP and, if indicated, supplemental oxygen or bilevel PAP/ASV per the policy’s therapy sequence.
• The policy notes limited data for phrenic nerve stimulation after failure of standard noninvasive treatments.

Required objective documentation — DISE and sleep study results for surgical/HNS PA

Objective documentation (e.g., DISE demonstrating absence of complete concentric collapse, sleep study results, and evidence of hypopharyngeal obstruction where relevant) is required to support certain surgeries and HNS eligibility and should be included with authorization requests.

• DISE findings must show absence of complete concentric collapse at the soft palate level for HNS candidacy.
• Include polysomnography/REI/AHI reports demonstrating the AHI thresholds required by the policy.

Device regulatory and implantation note — remedē System (PMA P160039)

Device implantation details: the remedē System is FDA-approved (PMA #P160039) for moderate to severe CSA in adults; implantation is performed by a cardiologist with external programming and follow-up — include device and implantation documentation if relevant to requests.

• Remedē System PMA #P160039 is referenced in the policy’s regulatory status section.
• Document the implanting clinician specialty and device programming/follow-up plans when relevant.

Billing note — use appropriate procedure codes (64568 for Inspire V)

Use the policy’s listed procedure codes when billing covered surgical treatments; for hypoglossal stimulation billing, procedure code 64568 may be used to bill the Inspire V Therapy System.

• Reference the covered surgical procedure mapping in the policy coding table when submitting claims and PAs.
• 64568 is noted as usable to bill the Inspire V Therapy System.

Policy history notes — reference prior revisions when documenting PA

Policy history documents prior changes to HNS indications, age and BMI criteria, and coding movements; providers should reference policy history when preparing documentation for authorization or appeals.

• History entries note changes such as addition of ≤100 AHI for adult HNS and pediatric age/BMI language modifications.
• Coding history documents moved and removed codes; review history to understand recent edits.

Suggested documentation to support coverage determination — include revised criteria

When submitting claims or PA requests for HNS or phrenic nerve stimulation, include documentation that the patient meets the revised clinical criteria (age, AHI, BMI or BMI percentile for pediatrics) and any prior authorization required by payer processes.

• For adult HNS include AHI within 15–100 and CPAP failure/intolerance evidence.
• For pediatric HNS include age ≥13 and BMI percentile documentation where applicable; for phrenic nerve stimulation note that the therapy is investigational.

Coding and criteria documentation — use updated code placements

Ensure submitted codes align with the policy’s current coding tables: removed codes (21299, 31600, 31601, 42870, 42975, E1399) should not be used and codes moved to non-covered lists (e.g., 41512) may result in denial.

• Do not submit claims using codes listed as removed from the policy.
• Verify that the procedure code you intend to bill is listed as covered in the most recent policy coding table.

Coding/documentation alignment — reflect current coding table placement

Documentation submitted for authorization should reflect current coding table placement; multiple procedure codes were removed and some moved to non-covered lists — update billing and clinical documentation accordingly.

• Align clinical notes and operative reports with the CPT/HCPCS codes currently listed as covered.
• If previously used codes were removed, select appropriate alternative covered codes per the policy mapping.

Coding update documentation — verify before submission

Ensure submitted codes reflect updated covered/non-covered placement; policy updates reference explicit procedure and CPT/HCPCS code changes — verify coding before PA or claims submission.

• Policy updates removed several codes and moved 41512 to non-covered; adjust claims and PA codes to current policy.
• Coding verification is recommended to avoid denials.

Removed procedure codes — do not use for coverage claims

The policy removed procedure codes 21299, 31600, 31601, 42870, 42975, and E1399; do not use these codes for coverage claims under this policy as they have been deleted from the policy coding sections.

• Claims billed with these removed codes may be denied or not recognized by payer systems.
• Replace removed codes with the correct currently covered code(s) per the policy mapping if applicable.

Documentation note for moved non-covered code — 41512 not covered

Providers should not expect coverage for services billed with code 41512 because the code was moved to the policy’s non-covered coding table; documentation may be required if reconsideration is requested but coverage is not standard.

• CPT 41512 is explicitly listed as non-covered in the policy coding table.
• If submitting for review, include detailed justification and any new evidence but anticipate likely denial based on current policy placement.

Coding updates and documentation — verify coding before submission

Verify coding prior to submission: the policy removed several procedure codes and moved others to non-covered lists; confirmation of code coverage status is recommended before requesting authorization or submitting claims.

• Check the policy coding table for the most recent covered, non-covered, and removed code listings.
• Incorrect coding may lead to claim denial or administrative delay.

Coding verification recommended — check updated tables before billing/PA

Providers should verify coding and coverage prior to submission because the policy revisions include coding table changes and device/service removals that affect authorization and claims.

• Confirm whether a procedure code is covered, moved to non-covered, or removed from the policy before billing.
• Use updated policy guidance when preparing PA requests to reduce risk of denial.

Support for coverage status — provide evidence when challenging investigational designation

Documentation should support whether a requested procedure is classified as covered versus investigational per the updated policy; include evidence (studies, prior therapy trials) if seeking coverage despite an investigational designation.

• For interventions labeled investigational (e.g., phrenic nerve stimulation for CSA), provide clinical justification and new supporting evidence if requesting an exception.
• Coverage determination will follow the policy’s investigational vs covered classification.

Documentation — updated policy sections referenced

Policy sections, background, rationale, and references were updated; providers should reference the updated policy sections for specific documentation requirements and code placements when preparing authorization requests or appeals.

• Refer to the updated Background, Policy Guidelines, Rationale, Coding Table, and References sections for complete requirements.
• Use the policy’s most recent effective/history notes to guide documentation content.

Required documentation for HNS and CSA procedures — reflect updated criteria

Required documentation for HNS and CSA procedures must reflect the revised criteria: adult HNS AHI ≤100; pediatric HNS lower age limit of 13 and BMI percentile-for-age language; note that phrenic nerve stimulation for CSA is listed as investigational.

• Include polysomnography demonstrating AHI within required thresholds and percent central apneas.
• For pediatric HNS include age documentation (≥13) and BMI percentile for age per policy.

Investigational procedures denied — noncompliant procedures at risk for denial

Procedures that do not meet the policy’s medical necessity criteria, including interventions labeled investigational (e.g., minimally invasive palatal/tongue procedures, implantable devices outside listed indications), may be denied as investigational or not medically necessary.

• Minimally invasive palatal or tongue procedures and implantable hypoglossal stimulators outside listed indications are considered investigational.
• Submit objective evidence of meeting medical necessity criteria to avoid denial.

Investigational / Not Covered — denial risk for investigational procedures

Procedures and phrenic nerve stimulation identified as investigational are not covered; claims using procedure codes for investigational treatments may be denied.

• Phrenic nerve stimulation for CSA is designated investigational and therefore not covered under this policy.
• Claims for investigational surgical treatments may be denied; do not anticipate coverage without policy change.

Investigational therapy denial risk — phrenic nerve stimulation (CSA)

Phrenic nerve stimulation for central sleep apnea is designated investigational in the policy; claims for this therapy are likely to be denied based on the investigational classification.

• Remedē System is FDA approved (background), but the policy lists phrenic nerve stimulation as investigational for coverage purposes.
• Authorization requests for phrenic stimulation should note investigational status and anticipate denial.

Investigational surgical treatments — risk of noncoverage

Surgical treatments for OSA that are designated investigational in the policy may be noncovered; verify whether a given surgical procedure is listed as covered or investigational in the policy prior to submitting claims.

• Refer to the policy’s Covered versus Investigational coding tables to determine coverage status for specific surgical procedures.
• Procedures marked investigational should not be billed expecting standard coverage.

Non-covered procedure code — CPT 41512 likely to be denied

Claims using procedure code 41512 may be denied because the code has been moved to the non-covered coding table; do not submit 41512 expecting coverage under this policy.

• Multiple policy entries state CPT 41512 moved to non-covered table — anticipate denial for claims using this code.
• If an alternative covered code exists, submit that code with appropriate documentation instead.

Non-covered procedure code — 41512 denial risk

Claims submitted with procedure code 41512 may be denied because the code was moved to the non-covered coding table; check the policy’s coding placement before billing.

• 41512 is repeatedly noted in the policy history and coding sections as moved to the non-covered table.
• Anticipate claim denial or the need for manual review if 41512 is used.

Removed procedure/device codes — claims may be denied

Claims using the removed procedure/device codes (21299, 31600, 31601, 42870, 42975, E1399) may be denied or not recognized by the payer because these codes were explicitly removed from the policy.

• Do not submit claims using these removed codes; they have been deleted from the policy coding sections.
• If a procedure corresponds to a removed code, use the appropriate currently covered CPT/HCPCS code per the policy mapping.

Removed procedure codes — no longer covered

Claims billed with removed codes (21299, 31600, 31601, 42870, 42975, E1399) will no longer be covered under this policy; confirm and use current covered codes to avoid denial.

• These specific procedure codes were removed from the policy and are noted in the policy history and coding tables.
• Billing with removed codes risks denial or non-recognition.