CurrentCignaPolicy 0158

Surgical Treatments for Obstructive Sleep Apnea

Cigna Medical Coverage Policy 0158 defines medical necessity criteria, exclusions, and coding for surgical treatments for obstructive sleep apnea including DISE, UPPP, multi-level/stepwise surgery, maxillomandibular advancement, and implanted upper airway hypoglossal nerve stimulation devices; also lists procedures considered experimental/unproven or not medically necessary and associated codes.

Policy Summary

PayerCigna

PolicySurgical Treatments for Obstructive Sleep Apnea

Policy CodePolicy 0158

Change TypeRevisions, additions, and removals (material)

Effective DateJun 15, 20269d

Next Review DateDec 15, 2026

Key ActionSubmit documentation showing PAP criteria and failure/intolerance, DISE findings (presence/absence of complete concentric collapse), device-specific age/AHI/BMI thresholds, and prior consideration of MRAs or other therapies as applicable.

SourceLink

POLICY UPDATE CHANGES

Revised policy statement for implantable upper airway hypoglossal nerve stimulation device in adults (BMI).

Revised policy statement for implantable upper airway hypoglossal nerve stimulation device in pediatric individual with Down syndrome (BMI).

Revised policy statement for drug-induced sleep endoscopy (DISE) in adults.

Revised policy statement for uvulectomy.

Removed policy statement for tongue implant (e.g., ReVENT Sleep Apnea System).

Removed statements and codes addressing tracheostomy, tonsillectomy and adenoidectomy.

Removed policy statements pertaining to replacement of generator battery and/or leads and laser-assisted uvulopalatoplasty (LAUP).

Added policy statements to address use of hypoglossal airway stimulation in adolescents with obstructive sleep apnea and Down syndrome.

Clarified statement addressing uvulectomy.

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.

Coverage Summary

Scope: Cigna Medical Coverage Policy 0158 (effective 6/15/2026) addresses surgical treatments for obstructive sleep apnea (OSA), defining medical necessity criteria, exclusions, and coding for procedures including drug-induced sleep endoscopy (DISE), uvulopalatopharyngoplasty (UPPP), multi-level or stepwise surgery (MLS), maxillomandibular advancement (MMA), and FDA-approved implanted upper airway hypoglossal nerve stimulation devices. The policy lists procedures considered experimental/unproven or not medically necessary and notes coding changes and removed statements.

Primary covered procedures summarized: DISE for evaluation of upper airway obstruction and device candidacy; UPPP when retropalatal collapse is demonstrated and PAP has failed or is not tolerated; MLS for multi-site upper airway narrowing with prior PAP failure/intolerance; MMA for severe OSA with craniofacial disproportion after PAP failure/intolerance; and implanted hypoglossal nerve stimulation for selected moderate-to-severe OSA patients meeting device-specific age, AHI, BMI, and DISE collapse criteria.

Key population change: the policy now explicitly includes adolescents (13–18 years) with Down syndrome as a covered pediatric population for FDA‑approved hypoglossal nerve stimulation when device-specific age/AHI/BMI criteria and other pediatric selection requirements are met.

Key thresholds & selection highlights

Policy number0158

Effective date6/15/2026

PAP failure (AHI)> 15 (inability to eliminate OSA)

PAP intolerance (usage)Unable to use PAP >4 hours/night on ≥5 nights/week

Inspire system - adult age/AHI/BMIAge ≥18 years; AHI ≥15 and ≤100 events/hr; BMI ≤40

Genio System 2.1 - adult age/AHI/BMIAge ≥22 years; AHI ≥15 and ≤65 events/hr; BMI ≤32

Pediatric (Inspire) - Down syndrome thresholdsAge 13–18 years; AHI >10 and <50 events/hr; BMI ≤95th percentile for age

Central/mixed apnea limitCentral + mixed apneas ≤25% of total AHI (exclusion if >25%)

Medical-Necessity Criteria

Drug-induced sleep endoscopy (DISE) - Adults

Render criteria_trees[0] (Drug-induced sleep endoscopy (DISE) - Adults) preserving the top-level intro and nested ANY logic.

ANY of the following

DISE for evaluation of upper airway surgery in an adult is medically necessary when EITHER of the following is met:
- Persistent OSA in an adult when criteria for positive airway pressure (PAP) are met and documentation demonstrates PAP treatment failure defined as an inability to eliminate OSA (apnea-hypopnea index [AHI] > 15).
- PAP intolerance, defined as inability to use PAP > 4 hours per night, 5 nights per week; OR unwillingness to use PAP (e.g., patient returns the PAP system after attempting to use it).
Persistent OSA after surgical intervention to treat OSA.

Coverage Context & Evidence

Hypoglossal Nerve Stimulation - Coverage Context

Hypoglossal nerve stimulation - Coverage Context: policy narrative, selection considerations, FDA/VA/DoD notes, and example devices

ALL of the following

Device examples: Device has FDA approval/clearance examples listed (Inspire II Identifier = P130008; Genio System 2.1 Identifier = P240024).
Evidence: Implanted hypoglossal nerve stimulation considered appropriate for carefully selected adult patients with moderate to severe OSA who are intolerant of or unwilling to use PAP (supported by prospective cohorts/registries; RCT evidence limited).
FDA / Manufacturer Limitations (Genio System 2.1) - safety/effectiveness NOT established in:
- Patients younger than 22 or older than 75 years of age

Not Covered / Experimental / Insufficient Evidence

Procedures/Technologies with Insufficient Evidence (Not Established as Safe and Effective)

The literature is judged insufficient to demonstrate safety/efficacy and long-term outcomes for these interventions in OSA:

ANY of the following

Atrial overdrive pacing - insufficient evidence to demonstrate safety and efficacy for OSA; cardiac pacing role unclear
Cautery-Assisted Palatal Stiffening Operation (CAPSO) - insufficient high-quality evidence; some case series show AHI and ESS improvement but lacking robust trials
Injection snoreplasty - no evidence demonstrating safety/efficacy in OSA
Pillar Palatal Implant System - FDA 510(k) cleared for snoring and mild-moderate OSA but literature insufficient to demonstrate long-term safety/efficacy; mixed short-term results

Coding

Considered Medically Necessary (when criteria met)mixedCovered

21193	Mandibular osteotomy, segmental; with advancement, with rigid fixation (e.g., genioglossus advancement)
21194	Mandibular osteotomy, segmental; with advancement, without rigid fixation
21195	Mandibular osteotomy, segmental; other
21196	Mandibular osteotomy, bilateral, with tooth-borne device
21198	Maxillary osteotomy, segmental; with advancement
21206	Mandible, augmentation; genioplasty, sliding
61886	Transoral robotic resection of tongue base
64568	Placement or replacement of peripheral nerve (e.g., hypoglossal) neurostimulator electrode array

Considered Not Medically Necessary (UPPP-related / snoring only)mixedNot Covered

K000036	Pillar™ Palatal Implant System (example HCPCS - removed/not covered)
K000778	Radiofrequency volumetric tissue reduction device related code (example - not covered)
K040417	Removed/Deleted product identifier - associated with palatal implants (not covered)
K110623	Removed/Deleted product identifier (not covered)

Considered Experimental/Investigational/UnprovenmixedExperimental

K971450	Transpalatal advancement/pharyngoplasty device identifier (investigational)
K973618	Tongue-base suspension device identifier (investigational)
K982717	Radiofrequency ablation device identifier (investigational)
K981677	AIRvance™ or similar tongue suspension product identifier (investigational)
K122391	Cautery-assisted palatal stiffening (CAPSO) device identifier (investigational)
K183310	Atrial overdrive pacing device identifier (investigational)
K201238	Injection snoreplasty product identifier (investigational)
K213159	Pillar™ or similar palatal implant product identifier (investigational)

FDA-listed devices / product identifiers mentionedmixed

Inspire	Inspire Upper Airway Stimulation System (FDA-approved hypoglossal nerve stimulation device)
Genio	Genio® System 2.1 (Nyxoah S.A.) (FDA-cleared/marked device)

Removed/Deleted codesmixedNot Covered

K040417	Removed product identifier (see policy notes)
K110623	Removed product identifier (see policy notes)
K971450	Removed/Deleted - reference prior coding guidance
K973618	Removed/Deleted - reference prior coding guidance
K982717	Removed/Deleted - reference prior coding guidance
K000036	Removed/Deleted - prior palatal implant code
K000778	Removed/Deleted - prior RF device code
K981677	Removed/Deleted - prior tongue suspension identifier
K122391	Removed/Deleted - prior CAPSO identifier
K183310	Removed/Deleted - prior atrial pacing identifier

1–10 of 12

1/2

Coder note: Use codes current as of the date of service; deleted or inactive codes (listed above) should not be billed and may be denied. For billing rules and prior authorization requirements, reference the provider actions and billing_rule entries in the policy (e.g., documentation of PAP failure/intolerance, device-specific warranty status for replacement remotes).

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization for implantable hypoglossal nerve stimulation

Prior authorization is required for implantable hypoglossal nerve stimulation devices. Submit documentation demonstrating that PAP criteria are met and provide evidence of PAP treatment failure (e.g., AHI thresholds) or PAP intolerance, presence/absence of complete concentric collapse on DISE, and device-specific age/AHI/BMI thresholds. Obtain prior authorization before device implantation.

42975
64582
L8686
L8688

Documentation Required

DISE and surgical indication documentation

For DISE, document the observed sites of obstruction and the clinical indication (e.g., persistent OSA, post-surgical OSA, or adjunct to other surgery in children). For UPPP/MLS/MMA document the anatomical sites of collapse and prior PAP efforts or intolerance. DISE must specifically document the absence of complete concentric collapse at the soft palate level when assessing candidacy for hypoglossal nerve stimulation.

Background & Definitions

Concise background for operational readers: PSG is the diagnostic gold standard for OSA. DISE is a minimally invasive diagnostic endoscopic evaluation of dynamic upper airway collapse that can inform surgical planning. In adults, behavior modification and PAP therapy are first‑line treatments; surgical options, including hypoglossal nerve stimulation, are considered for patients who fail, cannot tolerate, or decline PAP.

Term	Definition
{"text":"PAP failure","status":""},{"text":"Inability to eliminate OSA (AHI > 15 despite PAP usage).","status":""}
{"text":"PAP intolerance","status":""},{"text":"Inability to use PAP > 4 hours per night, 5 nights per week; or unwillingness to use PAP (e.g., patient returns the PAP system after attempting to use it).","status":""}
{"text":"Complete concentric collapse (CCC)","status":""},{"text":"Complete concentric collapse at the soft palate level observed on DISE; an exclusion for hypoglossal nerve stimulation eligibility.","status":""}
{"text":"AHI","status":""},{"text":"Apnea–Hypopnea Index — events per hour used to categorize OSA severity (mild, moderate, severe).","status":""}
{"text":"DISE","status":""},{"text":"Drug-Induced Sleep Endoscopy — endoscopic evaluation of airway collapse pattern during sedation to assess dynamic upper airway behavior.","status":""}

Medicare / Regulatory Determinations

effective date	name	number	type
{"text":"2014-04-30","status":""},{"text":"Inspire II Upper Airway Stimulator PMA","status":""},{"text":"P130008","status":""},{"text":"NCD / PMA (FDA PMA decision)","status":""}
{"text":"2025-08-08","status":""},{"text":"Genio System 2.1 PMA","status":""},{"text":"P240024","status":""},{"text":"PMA","status":""}

Revision History

2026-06-15policy_revisionLatest

Revised policy statement for implantable upper airway hypoglossal nerve stimulation device in adults (BMI). (Material change)

2026-06-15policy_revisionLatest

Revised policy statement for implantable upper airway hypoglossal nerve stimulation device in pediatric individual with Down syndrome (BMI). (Material change)

2026-06-15policy_revision

Evidence & Outcomes Highlights

Study / Source	Key finding / value
{"text":"STAR trial (Strollo et al., 2014)","status":""},{"text":"n=126; 60% achieved ≥50% decrease in AHI at 12 months; median AHI decreased from 29.3 to 9.0 events/hr.","status":""}
{"text":"Yu 2022 (adolescents with Down syndrome)","status":""},{"text":"n=42; mean AHI reduction 12.9 events/hr at 12 months; 65.9% achieved ≥50% AHI reduction; 73.2% had AHI <10 at 12 months; high nightly usage reported.","status":""}
{"text":"Meta-analysis - Wollny et al. (2024)","status":""},{"text":"Pooled mortality 0.01%; device survival probability 0.9834 at 60 months; low pooled surgical revision rate 0.08%.","status":""}
{"text":"Qi et al. (2024) DISE-guided surgery","status":""},{"text":"Overall median surgical failure rate 37% (95% CI 0.31–0.44); single-level 35%, multilevel 41%; higher baseline AHI and BMI associated with failure.","status":""}
{"text":"Kim et al. (2024) systematic review","status":""},{"text":"Included 10 studies (2 RCTs + 8 cohorts), 2209 individuals; hypoglossal stimulation effective alternative but limited RCTs and heterogeneity limit conclusions.","status":""}
{"text":"Meta-analysis - Liu et al. / pediatric Down syndrome reviews","status":""},{"text":"OSA prevalence in Down syndrome: up to 80% of children with Down syndrome affected vs ~5% of healthy children; pooled AHI reduction in adolescents in systematic reviews noted (mean reductions reported).","status":""}
{"text":"Wollny et al. / safety systematic review","status":""},{"text":"Adverse events primarily perioperative and acclimatization-related; low rates of serious device-related complications in pooled analyses.","status":""}
{"text":"Walker et al. (2025) MMA outcomes","status":""},{"text":"Improvements in AHI (~41.87/hour), ESS and other metrics; noted complications including facial numbness and hardware removal. ","status":""}

Policy Summary

PayerCigna

PolicySurgical Treatments for Obstructive Sleep Apnea

Policy CodePolicy 0158

Change TypeRevisions, additions, and removals (material)

Effective DateJun 15, 20269d

Next Review DateDec 15, 2026

SourceLink

On This Page

DISE - Adolescent with Down syndrome

Render criteria_trees[1] (DISE - Adolescent with Down syndrome) preserving ALL logic and device-specific evaluation purpose.

ALL of the following

Adolescent age 13-18 with Down syndrome.
DISE performed to evaluate appropriateness for a U.S. Food and Drug Administration (FDA)-approved implantable upper airway hypoglossal nerve stimulation device.

See device-specific pediatric selection criteria elsewhere in this section (age, AHI, BMI, absence of complete concentric collapse, failure/intolerance of adenotonsillectomy and PAP, and consideration of other therapies).

DISE - Child

Render criteria_trees[2] (DISE - Child) preserving the EITHER/ANY logic and surgical-conjunction mention.

ANY of the following

Evaluation of persistent OSA after surgical intervention to treat OSA.
Evaluation of suspected OSA (e.g., observed restlessness with sleep, apneic periods, sleep disturbance, snoring, sleepiness upon awakening or during daytime) when performed in conjunction with other surgery (e.g., tonsillectomy, adenoidectomy, nasal or sinus surgery).

Uvulopalatopharyngoplasty (UPPP) - Adults

Render criteria_trees[3] (Uvulopalatopharyngoplasty (UPPP) - Adults) preserving the ALL logic and mention of prior MRA/tongue-retaining appliance consideration.

ALL of the following

Demonstrated narrowing or collapse of the retropalatal region (soft palate, uvula, tonsils, posterior pharyngeal wall) as a source of airway obstruction.
Criteria for PAP met and documentation that demonstrates PAP treatment failure defined as an inability to eliminate OSA (AHI > 15); OR PAP intolerance defined as inability to use PAP > 4 hours per night, 5 nights per week; OR unwillingness to use PAP (e.g., patient returns the PAP system after attempting to use it).
For OSA in an adult, consideration has also been given to use of a mandibular repositioning appliance (MRA) or tongue-retaining appliance.

Uvulectomy

Render criteria_trees[4] (Uvulectomy) to show coverage stance (not medically necessary for stand-alone uvulectomy for OSA).

ALL of the following

Uvulectomy as a stand-alone procedure for the treatment of OSA is considered not medically necessary.
Uvulectomy performed for other indications (e.g., airway obstruction, acute inflammation/angioedema of the uvula, globus sensation, coughing, choking, or gagging due to elongated uvula) is not addressed in this Coverage Policy.

Multi-level or stepwise surgery (MLS)

Render criteria_trees[5] (Multi-level or stepwise surgery (MLS)) preserving ALL logic and prior PAP/MRA considerations.

ALL of the following

Narrowing of multiple sites in the upper airway.
Criteria for PAP met and documentation that demonstrates PAP treatment failure defined as an inability to eliminate OSA (AHI > 15); OR PAP intolerance defined as inability to use PAP > 4 hours per night, 5 nights per week; OR unwillingness to use PAP (e.g., patient returns the PAP system after attempting to use it).
In an adult, a mandibular repositioning appliance (MRA) or tongue-retaining appliance has been considered and found to be ineffective or undesirable.

Maxillomandibular advancement (MMA)

Render criteria_trees[6] (Maxillomandibular advancement (MMA)) preserving ALL logic including craniofacial disproportion requirement.

ALL of the following

Criteria for PAP met and documentation that demonstrates PAP treatment failure defined as an inability to eliminate OSA (AHI > 15); OR PAP intolerance defined as inability to use PAP > 4 hours per night, 5 nights per week; OR unwillingness to use PAP (e.g., patient returns the PAP system after attempting to use it).
In an adult, a mandibular repositioning appliance (MRA) or tongue-retaining appliance has been considered and found to be ineffective or undesirable.
Individual has craniofacial disproportion or deformities.

FDA-approved implanted upper airway hypoglossal nerve stimulation device - Adults

Render criteria_trees[7] (FDA-approved implanted upper airway hypoglossal nerve stimulation device - Adults) preserving ALL logic including absence of CCC and PAP failure/intolerance requirements; include note to see device-specific thresholds.

ALL of the following

Meets device-specific age, AHI on polysomnography (PSG), and body mass index (BMI) thresholds (see device-specific thresholds).
Device-specific thresholds: Inspire System: age ≥18 years; AHI ≥15 and ≤100 events/hour; BMI ≤40. Genio System 2.1: age ≥22 years; AHI ≥15 and ≤65 events/hour; BMI ≤32.
Central + mixed apneas ≤ 25% of total AHI.
Absence of a complete concentric collapse at the soft palate level on drug-induced sleep endoscopy (DISE).
Documentation that demonstrates EITHER PAP treatment failure defined as an inability to eliminate OSA (AHI ≥15); OR PAP intolerance defined as inability to use PAP > 4 hours per night, 5 nights per week; OR unwillingness to use PAP (e.g., patient returns the PAP system after attempting to use it).

Also require absence of contraindications to the device and that all other indicated evaluation steps (including DISE when indicated) are documented.

Device is medically necessary for pediatric individuals with Down syndrome

Render criteria_trees[8] (Device is medically necessary for pediatric individuals with Down syndrome) preserving ALL logic and pediatric-specific selection criteria.

ALL of the following

Age, AHI on PSG, and BMI meet device-specific pediatric thresholds.
Absence of complete concentric collapse at the soft palate level on DISE.
Contraindicated for, or not effectively treated by, adenotonsillectomy.
Confirmed to have failed, or cannot tolerate, PAP therapy despite attempts to improve compliance.
All other alternative or adjunct therapies have been considered.

Example pediatric device-specific thresholds (Inspire System for Down syndrome adolescents): age 13-18 years; AHI >10 and <50 events per hour; BMI ≤ 95th percentile for age. See device labeling for exact selection criteria.

Replacement remote for hypoglossal nerve stimulation device

Render criteria_trees[9] (Replacement remote for hypoglossal nerve stimulation device) preserving coverage stance for remote replacement and noncoverage of off-the-shelf batteries.

ALL of the following

Replacement of a remote used with an FDA-approved implantable upper airway hypoglossal nerve stimulation device is medically necessary when documentation confirms the remote is malfunctioning and is no longer under warranty.
Off-the-shelf batteries used in the remote are generally considered not medically necessary because they are not primarily medical in nature.

VA/DoD / FDA selection considerations noted

FDA (per VA/DoD summary) clearance for adults >=18 with BMI <=40 kg/m2 (device originally tested in BMI <32 kg/m2) and moderate-to-severe OSA (AHI 15-100 events/hr) who failed/intolerant to PAP.
Not for use if central/mixed apneas >25% of total AHI
Not for patients with physical conditions preventing device efficacy (e.g., markedly enlarged tonsils) or those unable to operate the remote or without assistance
Contraindicated in pregnancy or planned pregnancy, those requiring MRI beyond device conditional labeling, or with other implantable devices that may interact
DISE should document absence of complete concentric velopharyngeal collapse

Evidence summary: Adult hypoglossal nerve stimulation evidence is dominated by prospective cohorts/registries and case series; randomized controlled trials are limited. The STAR trial (Strollo et al., 2014) reported that 60% of participants achieved ≥50% reduction in AHI at 12 months and median AHI decreased from 29.3 to 9.0 events/hour, with durability in follow-up.

Systematic reviews/meta-analyses (e.g., Kim et al. 2024; Wollny et al. 2024) pool primarily observational data and report favorable safety and device survival metrics but note heterogeneity, few RCTs, and limitations in adverse event reporting.

Pediatric evidence for adolescents with Down syndrome includes Yu et al. (2022) (n=42), which found a mean AHI decrease of 12.9 events/hour at 12 months, with 65.9% achieving ≥50% AHI reduction and 73.2% having AHI <10 at 12 months; safety events were generally limited and reoperation rate was low.

Overall evidence quality: limited high-quality RCT data, reliance on registries/cohorts and small pediatric series; systematic reviews highlight moderate-to-low certainty and the need for larger, longer-term controlled studies.

Background clinical context: attended in-laboratory polysomnography (PSG) is the diagnostic gold standard for OSA and is used to quantify severity (AHI). Drug‑induced sleep endoscopy (DISE) is a diagnostic tool performed under sedated sleep to visualize dynamic upper airway collapse and may guide surgical decision-making in select adults, adolescents with Down syndrome, and children.

First-line adult management emphasizes behavior modification and positive airway pressure (PAP) therapy (e.g., CPAP); surgical treatments, including hypoglossal nerve stimulation and other procedures, are positioned as second-line options for patients who are unresponsive to, unable to tolerate, or decline PAP therapy.