CurrentCignaPolicy 0158

Surgical Treatments for Obstructive Sleep Apnea

Defines medical necessity, exclusions, and coding for surgical treatments for OSA including DISE, UPPP, multi-level/stepwise surgery, maxillomandibular advancement, implanted upper airway hypoglossal nerve stimulation devices, uvulectomy, and other procedures; includes age/BMI/AHI/device-specific criteria and lists codes considered medically necessary, not necessary, or experimental/unproven.

Policy Summary

PayerCigna

PolicySurgical Treatments for Obstructive Sleep Apnea

Policy CodePolicy 0158

Change TypeRevised/Added/Removed statements

Effective DateJun 15, 20268d

Next Review DateDec 15, 2026

Key ActionProvide documentation demonstrating PAP treatment failure or PAP intolerance and submit claims with covered diagnosis and procedure codes per the revised policy criteria.

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).

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

Removed statements and codes addressing tracheostomy, tonsillectomy and adenoidectomy.

Updated coverage statement addressing use of hypoglossal airway stimulation in adults, based on current FDA language.

Updated to new template and formatting standards and removed statements pertaining to replacement of generator battery and/or leads and LAUP.

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.

2026-06-15Effective date

2026-12-15Next review

0158Policy number

Moderate-to-severe OSAPrimary adult indication for hypoglossal nerve stimulation

65.9%Pediatric Down syndrome 12-month response rate

InsufficientEvidence for many palate/tongue procedures long-term outcomes

Coverage Summary

Overview: This policy (effective 2026-06-15, last reviewed 2026-06-15) addresses surgical treatments for obstructive sleep apnea (OSA) and defines medical necessity, exclusions, and coding for multiple procedures. The primary adult indication highlighted is treatment of moderate-to-severe OSA with select surgical approaches.

Coverage is mixed: some procedures and diagnostics are considered medically necessary when specific criteria are met (e.g., drug-induced sleep endoscopy [DISE], uvulopalatopharyngoplasty [UPPP], multi-level/stepwise surgery [MLS], maxillomandibular advancement [MMA], and FDA-approved implanted hypoglossal nerve stimulation devices), while other procedures are considered experimental/unproven or not medically necessary.

Implanted hypoglossal nerve stimulation is covered for carefully selected adults when device-specific criteria (age, AHI, BMI, central/mixed apnea percentage, absence of complete concentric collapse on DISE, and documented PAP failure/intolerance) are met; device-specific thresholds and pediatric Down syndrome criteria are called out separately in the policy.

Key thresholds & quick-reference limits (AHI, PAP, device-specific limits)

AHI thresholds (adult) - InspireAHI ≥15 and ≤100 events/hr

AHI thresholds (adult) - GenioAHI ≥15 and ≤65 events/hr

PAP failure/intolerance thresholdPAP failure: inability to eliminate OSA (AHI >15 despite PAP); PAP intolerance: inability to use PAP >4 hrs/night, 5 nights/week or unwillingness to use PAP

Device age limitsInspire adults: ≥18 years (also noted 18–21 eligible per FDA supplement); Genio adults: ≥22 years

Device BMI limitsInspire BMI ≤40; Genio BMI ≤32 (Genio label excludes BMI >32)

Central/mixed apnea limitCentral + mixed apneas ≤25% of total AHI (exceeding excludes candidacy)

Notable exclusions/contraindicationsComplete concentric collapse (CCC) at soft palate level excludes candidacy; Genio excludes patients <22 or >75 years, BMI >32, AHI <15 or >65; some pediatric studies exclude AHI ≥50

Medical Necessity Criteria (grouped)

Drug-Induced Sleep Endoscopy (DISE) – Adults

DISE is medically necessary for the evaluation of upper airway surgery in an adult when EITHER of the following is met:

ANY of the following

Persistent OSA when criteria for positive airway pressure (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 of use per night, 5 nights per week; OR unwillingness to use PAP (e.g., a patient returns the PAP system after attempting to use it).
Persistent OSA after surgical intervention to treat OSA.

DISE – Adolescent with Down syndrome (age 13-18)

DISE is medically necessary to evaluate appropriateness of an FDA-approved implantable hypoglossal nerve stimulation device when ALL of the following apply:

Not Medically Necessary and Experimental/Unproven Procedures

Not Medically Necessary / Experimental Procedures (summary)

Summary coverage stance and emphasis on uvulectomy and experimental procedures:

Not Medically Necessary: Uvulectomy as a stand-alone procedure for the treatment of OSA is considered not medically necessary.

Experimental/Unproven Procedures: Atrial overdrive pacing; CAPSO; injection snoreplasty; Pillar™ Palatal Implant System; RFVTR of the soft palate/uvula/tongue base (e.g., Coblation®, Somnoplasty®); tongue-base suspension (e.g., AIRvance™, ENCORE™); transpalatal advancement pharyngoplasty (TPAP)

These procedures are considered experimental, investigational, or unproven for OSA.

Considered Not Medically Necessary for treatment of OSA (Uvulectomy as standalone / Snoring alone)CPTNot Covered

42140

Uvulectomy, excision of the uvula

Considered Experimental/Investigational/Unproven for treatment of sleep apneaCPT|HCPCSExperimental

41512	Tongue base suspension, permanent suture technique.
41530	Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session.
42160	Destruction of lesion, palate or uvula (thermal, cryo or chemical).
42299	Unlisted procedure, palate, uvula (used to report CAPSO, injection Snoreplasty, or transpalatal advancement pharyngoplasty).
C9727	Insertion of implants into the soft palate; minimum of three implants.

Coding (by coverage status)

Considered Medically Necessary when policy criteria metCPT|HCPCSCovered

21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft.
21194	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft).
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation.
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation.
21198	Osteotomy mandible segmental.
21199	Osteotomy, mandible, segmental; with genioglossus advancement.
21206	Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard).
21685	Hyoid myotomy and suspension.
42145	Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty).
42975	Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep-disordered breathing, flexible, diagnostic.

1–10 of 20

1/2

Considered Not Medically Necessary for treatment of OSA (Uvulectomy as standalone / Snoring alone)CPTNot Covered

42140

Uvulectomy, excision of the uvula

Considered Experimental/Investigational/Unproven for treatment of sleep apneaCPT|HCPCS|CExperimental

41512	Tongue base suspension, permanent suture technique.
41530	Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session.
42160	Destruction of lesion, palate or uvula (thermal, cryo or chemical).
42299	Unlisted procedure, palate, uvula (used to report CAPSO, injection Snoreplasty, or transpalatal advancement pharyngoplasty).
C9727	Insertion of implants into the soft palate; minimum of three implants.

FDA device identifiers and product codes mentionedmixed

P130008	Inspire II Upper Airway Stimulator (Inspire Medical Systems), Decision Date 4/30/2014; FDA product code MNQ
P240024	Genio System 2.1 (Nyxoah S.A.), Decision Date 8/8/2025; FDA product code MNQ
K040417	Pillar Palatal Implant System (Restore Medical Inc.), Decision Date 07/28/2004; FDA product code LRK
K110623	Pillar Palatal Implant System (Medtronic Xomned, Inc.), Decision Date 02/10/2012; FDA product code LRK
K971450	Somnoplasty System (Somnus Medical Technologies), Decision Date 7/17/1997; FDA product code GEI
K973618	Somnoplasty System (Somnus), Decision Date 12/19/1997; FDA product code GEI
K982717	Somnoplasty System (Somnus), Decision Date 11/02/1998; FDA product code GEI
K000036	ENTec Reflex Wand (ArthroCare Corp.), Decision Date 02/04/2000; FDA product code GEI
K000778	ENTec Reflex Wand (ArthroCare Corp.), Decision Date 05/03/2000; FDA product code GEI
K981677	Repose Bone Screw System (Influence, Inc.), Decision Date 8/27/1999; FDA product code LRK/ORY

1–10 of 14

1/2

Removed procedure codes/statements (document notes removal of policy statements and codes)mixedNot Covered

Not specified	Statements and codes addressing tracheostomy, tonsillectomy and adenoidectomy removed from policy (codes not listed in this part)
Not specified	Statements and codes for tongue implant (e.g., ReVENT® Sleep Apnea System) removed

Removed procedure codes/statements (document notes removal of policy statements and codes)mixed

Not specified

Removed statements and codes addressing tracheostomy, tonsillectomy and adenoidectomy noted in revision history

Provider Actions and Authorization Requirements

Prior Authorization

Use appropriate codes and medical necessity documentation

Claims for services related to surgical treatment of OSA (including DISE and implantable hypoglossal nerve stimulation devices and accessories) must be submitted with the most appropriate and current CPT/HCPCS codes as of the date of service and include documentation supporting medical necessity. Prior authorization may be required per the member's benefit plan — include operative reports, DISE findings, polysomnography/HSAT reports showing AHI, PAP usage logs or device return documentation, and device-specific contraindication checks when submitting for authorization.

Documentation Required

Document PAP failure/intolerance

Provide documentation demonstrating either PAP treatment failure or PAP intolerance when required by the policy. PAP treatment failure is defined as inability to eliminate OSA (AHI > 15). PAP intolerance is defined as inability to use PAP > 4 hours per night, 5 nights per week. Alternatively, document patient unwillingness to use PAP (for example, return of PAP system after attempting use). Include PAP device download reports, clinic notes documenting trials, and any attempts to optimize PAP prior to declaring failure or intolerance.

Background and Evidence Summary

Clinical context: The gold-standard diagnostic test for OSA is attended in-laboratory polysomnography (PSG); home sleep apnea testing (HSAT) is also referenced for diagnosis and for pre/post-procedure testing when applicable.

DISE utility: Drug-Induced Sleep Endoscopy (DISE) is a minimally invasive, dynamic endoscopic assessment performed during anesthetically simulated sleep to visualize sites of upper airway collapse; DISE may guide surgical decision-making and is medically necessary for specified adult, adolescent (Down syndrome), and pediatric indications.

First-line treatments: In adults, initial management emphasizes behavior modification (weight loss, positional therapy, avoidance of alcohol/medications) and positive airway pressure (PAP) therapy; oral appliances may be appropriate. Surgical options, including UPPP, MLS, MMA, and implanted hypoglossal nerve stimulation, are considered for select patients who are unresponsive to, intolerant of, or decline PAP therapy.

Surgical options and indications: UPPP and MLS are medically necessary when anatomic obstruction is documented and PAP failure/intolerance or unwillingness is demonstrated. MMA is reserved for severe/persistent OSA, particularly with craniofacial disproportion. Implanted upper airway hypoglossal nerve stimulation devices are an option for carefully selected patients intolerant of or unresponsive to PAP, subject to device-specific labeling and exclusions.

Study/Metric	Value
STAR trial (Strollo et al., 2014)	Median AHI decreased 68% (29.3 to 9.0 events/hr); 60% achieved ≥50% decrease in AHI at 12 months; effects maintained up to 5 years; device-related surgical complications requiring device removal/replacement in 6% at 5 years.
Systematic review - Kim et al. (2024)	Included 10 studies (2 RCTs, 8 cohorts); hypoglossal stimulation showed mixed comparative results vs airway surgeries and may be an effective alternative for CPAP-intolerant moderate-to-severe OSA.
Pediatric Down syndrome cohort - Yu et al. (2022)	Mean AHI decrease 12.9 events/hr; 65.9% response rate (≥50% AHI reduction) at 12 months; 73.2% had AHI <10 at 12 months; nightly use ~9 hrs; low reoperation rate (4.8%).
MMA outcomes (Holty & Guilleminault 2010)	Mean AHI decreased from 63.9/hr to 9.5/hr; pooled surgical success 86% and cure (AHI<5) 43.2%; complication rates noted (major 1%, minor 31%).
Safety systematic review - Wollny et al. (2024)	Pooled mortality 0.01%; device survival probability 0.9834 at 60 months; low pooled surgical revision and adverse event rates (revision 0.08%).
DISE-guided surgery systematic review (Qi et al., 2024)	Overall median surgical failure rate 37% (95% CI 0.31–0.44); single-level 35%, multi-level 41%; identified risk factors for failure including circumferential velum collapse and higher BMI/AHI.
OSA prevalence in Down syndrome	Up to 80% of children with Down syndrome affected by OSA.
Noted disparities — severity in Black men at diagnosis	Study of 890 newly diagnosed patients: Black men had mean AHI 52.4 ± 39.4/hr vs White men 39.0 ± 28.9/hr, suggesting greater disease severity and delayed diagnosis.

Definitions & Thresholds

PAP failure: Inability to eliminate OSA (AHI > 15 despite PAP usage).

PAP intolerance: Inability to use PAP > 4 hours/night on at least 5 nights/week, or unwillingness to use PAP (e.g., returns PAP system after attempt).

Complete concentric collapse (CCC): Complete circumferential collapse at the soft palate/velopharynx level on DISE; absence of CCC is required for candidacy for some implantable devices.

AHI: Apnea-Hypopnea Index (events per hour) — used as a severity and eligibility metric in device and surgical criteria.

Quick-reference thresholds (AHI ranges, PAP usage, device age/BMI, central apnea/CCC)

AHI ranges (adults) - Inspire≥15 to ≤100 events/hr

AHI ranges (adults) - Genio≥15 to ≤65 events/hr

PAP usage threshold for intoleranceUnable to use PAP >4 hours/night on ≥5 nights/week (usage <4 hrs/night or <5 nights/week = intolerance)

Revision History

12/15/2024annual_review

Annual review added adolescent Down syndrome guidance and updated adult hypoglossal stimulation coverage to align with FDA language; administrative template/format updates and removal of certain procedural statements noted in 12/15/2024 revisions.

03/15/2026annual_review

Annual review revised DISE policy in adults, clarified uvulectomy statement, removed tongue implant statements/codes (e.g., ReVENT®), and removed statements/codes addressing tracheostomy, tonsillectomy and adenoidectomy.

06/15/2026focused_reviewLatest

Policy Summary

PayerCigna

PolicySurgical Treatments for Obstructive Sleep Apnea

Policy CodePolicy 0158

Change TypeRevised/Added/Removed statements

Effective DateJun 15, 20268d

Next Review DateDec 15, 2026

Key ActionProvide documentation demonstrating PAP treatment failure or PAP intolerance and submit claims with covered diagnosis and procedure codes per the revised policy criteria.

SourceLink

On This Page

Adolescent aged 13-18 with Down syndrome.

Evaluation is to assess appropriateness for an FDA-approved implantable upper airway hypoglossal nerve stimulation device.

DISE – Child

DISE is medically necessary in a child for EITHER of the following:

Evaluation of persistent OSA after surgical intervention to treat OSA.

Evaluation of suspected OSA (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

UPPP is medically necessary for treatment of OSA when ALL of the following are met:

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 demonstrating PAP treatment failure defined as inability to eliminate OSA (AHI > 15); OR PAP intolerance defined as inability to use PAP > 4 hours/night, 5 nights/week; OR unwillingness to use PAP (e.g., patient returns PAP system after attempting to use it).

For OSA in an adult, consideration has also been given to use of mandibular repositioning appliance (MRA) or tongue-retaining appliance.

Uvulectomy

Coverage stance for uvulectomy:

Uvulectomy as a stand-alone procedure for the treatment of OSA is considered not medically necessary.

Uvulectomy performed for other indications (airway obstruction, acute inflammation/angioedema of the uvula, globus sensation, coughing, choking, or gagging symptoms due to elongated uvula) is not addressed in this Coverage Policy.

Multi-level or Stepwise Surgery (MLS)

MLS is medically necessary for treatment of OSA when ALL of the following criteria are met:

Narrowing of multiple sites in the upper airway.

In an adult, an MRA or tongue-retaining appliance has been considered and found to be ineffective or undesirable.

FDA-Approved Implantable Upper Airway Hypoglossal Nerve Stimulation Devices – Adults

An FDA-approved implantable upper airway hypoglossal nerve stimulation device is medically necessary for treatment of moderate to severe OSA in an adult when ALL of the following criteria are met:

Age, AHI on polysomnography (PSG), and BMI (device-specific thresholds noted in policy).

See device-specific thresholds for Inspire and Genio

Central + mixed apneas ≤ 25% of total AHI.≤ 25%

Absence of a complete concentric collapse at the soft palate level on drug induced sleep endoscopy.

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/night, 5 nights/week; OR unwillingness to use PAP (e.g., patient returns PAP system after attempting to use it).AHI ≥ 15 or PAP usage thresholds

Implanted Hypoglossal Nerve Stimulation – Device-specific thresholds

Device-specific age/AHI/BMI limits called out in the policy:

Inspire Upper Airway Stimulation System (Inspire Medical Systems): Age ≥ 18 years; AHI on PSG ≥ 15 and ≤ 100 events per hour; BMI ≤ 40.Age ≥18; 15≤AHI≤100; BMI≤40

Genio System 2.1 (Nyxoah S.A.): Age ≥ 22 years; AHI on PSG ≥ 15 and ≤ 65 events per hour; BMI ≤ 32.Age ≥22; 15≤AHI≤65; BMI≤32

Implanted Hypoglossal Nerve Stimulation – Pediatric with Down syndrome

An FDA-approved implantable upper airway hypoglossal nerve stimulation device is medically necessary for treatment of OSA in a pediatric individual with Down syndrome when ALL of the following criteria are met:

Age, AHI on PSG, and BMI meet device-specific limits (policy notes Inspire: age 13-18; AHI > 10 and < 50; BMI ≤ 95th percentile for age).Age 13-18; 10<AHI<50; BMI≤95th percentile

Absence of complete concentric collapse at the soft palate level.

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/adjunct therapies have been considered.

Replacement Remote for Hypoglossal Nerve Stimulation Device

Replacement remote coverage criteria:

Replacement of a remote 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 (not primarily medical in nature).

Additional Procedures/Services – Experimental/Unproven

The following procedures for treatment of OSA are considered experimental, investigational or unproven:

Atrial overdrive pacing

Cautery-assisted palatal stiffening operation (CAPSO)

Injection snoreplasty

Pillar™ Palatal Implant System

Radiofrequency volumetric tissue reduction (RFVTR) of the soft palate, uvula, or tongue base (e.g., Coblation®, Somnoplasty®)

Tongue-base suspension (e.g., AIRvance™ System, ENCORE™ Tongue Suspension System)

Transpalatal advancement pharyngoplasty (TPAP)

Treatment of Snoring Alone

Policy stance:

Treatment of snoring alone by any method is considered not medically necessary.

Hypoglossal nerve stimulation — applicability and FDA-labeled exclusions (narrative)

Coverage limited to carefully selected patients intolerant of or unwilling to use PAP; FDA and device manuals list groups where safety/effectiveness not established:

Patients are candidates only after failure of or intolerance to positive airway pressure (PAP) therapy.

Any of the following: Patient age younger than 22 years

(Genio label excludes <22)

Any of the following: Patient age older than 75 years

(Genio label excludes >75)

Any of the following: Body Mass Index (BMI) greater than 32 kg/m2BMI>32

(Genio label)

Any of the following: Apnea Hypopnea Index (AHI) less than 15 events/hrAHI<15

(Genio label excludes)

Any of the following: Apnea Hypopnea Index (AHI) greater than 65 events/hrAHI>65

(Genio label excludes)

Any of the following: Complete Concentric Collapse (CCC) at the soft palate level

Pediatric selection and exclusions narrative

Studies of adolescents with Down syndrome used selection criteria limiting applicability:

Typical inclusion: age range ~10-22 years with Down syndrome and persistent severe OSA despite adenotonsillectomy and inability to tolerate PAP or dependence on tracheostomy

Common exclusions in pediatric cohorts: central apnea contribution > 25% of total AHI; BMI > 95th percentile; medical condition requiring future MRI (contraindication per study); DISE findings consistent with circumferential palatal (velopharyngeal) collapse; AHI ≥ 50 events per hour (some studies excluded such patients)

Other surgical/device treatments assessed — evidence stance

Summary determinations from literature reviews and professional society statements:

Atrial overdrive pacing: insufficient evidence to demonstrate safety and efficacy for OSA.

Cautery-Assisted Palatal Stiffening Operation (CAPSO): insufficient evidence to demonstrate safety, efficacy, and long-term outcomes.

Injection snoreplasty: no evidence demonstrating safety and efficacy for OSA.

Pillar Palatal Implant System: insufficient evidence for long-term safety/efficacy for OSA despite FDA 510(k) clearances; mixed short-term results.

Radiofrequency volumetric tissue reduction (RFVTR) of soft palate/uvula/tongue base: insufficient evidence to demonstrate safety, efficacy, and long-term outcomes for OSA.

Tongue-base suspension (e.g., Encore, AIRvance/Repose): insufficient evidence to support safety/efficacy and long-term outcomes; AAO-HNS provides conditional recommendations for selected patients.

Transpalatal advancement pharyngoplasty (TPAP): insufficient evidence; mainly retrospective data.

Documentation Required

DISE and collapse documentation

Perform and document a drug-induced sleep endoscopy (DISE) to evaluate the pattern of upper airway collapse, including assessment for palatal complete concentric collapse (CCC). For hypoglossal nerve stimulation device candidacy, explicitly document absence of CCC at the soft palate level. Include the DISE operative report and findings in the authorization packet.

CPT 42975 — diagnostic endoscopy, upper airway (DISE); document findings, including presence/absence of palatal complete concentric collapse (CCC)

Billing Rule

Replacement remote coverage

Replacement remotes for FDA‑approved implantable hypoglossal nerve stimulation systems are covered when documentation confirms the remote is malfunctioning and is no longer under warranty. Off‑the‑shelf batteries for remotes are generally not covered.

HCPCS C1787
HCPCS L8681
Coverage only when remote malfunction is documented and unit is out of warranty; batteries not covered

Denial Risk

Risk of coverage denial if exclusion criteria present

Risk of coverage denial increases when exclusion or contraindication criteria are present. Common reasons for denial include: patient BMI or AHI outside the device-specific policy ranges, presence of complete concentric collapse (CCC) on DISE, central apneas comprising > 25% of total AHI, and lack of documentation demonstrating PAP failure or intolerance. Also verify device-specific contraindications (e.g., age, BMI thresholds, prior surgeries, anatomic exclusions) prior to authorization submission.

Documentation Required

Refer to revised policy criteria

Refer to the revised policy criteria effective 6/15/2026 for exact thresholds and device-specific requirements (age, AHI ranges, BMI limits, and other criteria). Providers must follow the updated policy statements and consult the full policy for complete eligibility and documentation requirements prior to submitting authorization requests.

Device age/BMI limits (Inspire)

Age ≥18 years (also noted 18–21 eligible); BMI ≤40

Device age/BMI limits (Genio)Age ≥22 years; BMI ≤32 (Genio label excludes BMI >32)

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

Central apnea % and CCCCentral + mixed apneas must be ≤25% of total AHI; absence of complete concentric collapse at soft palate required

Focused review revised adult and pediatric (Down syndrome) hypoglossal nerve stimulation BMI-related policy statements and updated criteria; policy effective date set to 2026-06-15.