Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Clinical policy governing medical necessity and coverage criteria for implantable hypoglossal (upper airway) nerve stimulation devices for obstructive sleep apnea in members/enrollees covered by the Health Plan.
Updated criteria B from 'Age > 22 years' to 'BMI ≤ 40 kg/m2' and changed criteria C to add age-range-specific subcriteria C.1–C.3 per FDA updates (Inspire Upper Airway Stimulation System).
Added criteria II stating that drug-induced sleep endoscopy (DISE) is medically necessary when completed to evaluate appropriateness of a hypoglossal nerve stimulation device.
Updated apnea-hypopnea index (AHI) thresholds in criteria I.C.3.a and I.A.3.c.i (e.g., changed AHI bounds to ≥15 and ≤100; and AHI >10 and <50).
Added contraindication noting rhabdomyolysis as a contraindication.
Added CPT codes 64568 and 64569 for Inspire V to the coding table.
Added Criteria I.B. for the Genio System and background information on Genio.
Coverage Criteria for Implantable Hypoglossal Nerve Stimulation
Device-specific candidate selection and preoperative evaluation
Covered when device- and patient-specific preoperative selection criteria and evaluations are met:
Complete, detailed criteria text (full subpoints) are not included in the excerpt; implementers should reference the full policy text for exact subcriterion mapping.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.