Surgery for Obstructive Sleep Apnea — Clinical Coverage Criteria
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Clinical coverage criteria governing prior authorization and medical necessity determinations for surgical treatments of obstructive sleep apnea for Fallon Health plan members, including Medicare Advantage and Community Care products; includes references to InterQual criteria and exclusions.
Effective for dates of service on or after January 1, 2026, Fallon Health will use InterQual® Criteria when making medical necessity determinations for surgery for obstructive sleep apnea for plan members 18 years of age and older.
Prior authorization by a Fallon Health Medical Director is required for surgery for obstructive sleep apnea.
Coverage criteria for surgical treatment of obstructive sleep apnea
Surgical coverage criteria and exclusions
Covered when ALL of the following are met:
Refer to InterQual® CP: Procedures, Orthognathic Surgery for Obstructive Sleep Apnea and InterQual® CP: Procedures, Uvulopalatopharyngoplasty (UPPP).
UPPP requires review by a Plan Medical Director.
AHI/RDI thresholds: Mild ≥5 to <15; Moderate ≥15 to <30; Severe ≥30; UPPP not recommended at AHI/RDI ≥40.
ALL of the following
- Laser assisted uvulopalatoplasty (LAUP) (HCPCS S2080)
- Palate reduction with the Somnoplasty System (Somnus Medical Systems)
- Implantation of palatal implants (Pillar Procedure)
- Tongue base suspension procedures (including AIRvance® and Encore™ systems)
- Submucosal ablation of the tongue base, radiofrequency (CPT 41530)
- Coblation tongue base reduction
Coverage stance and applicable decision sources
Fallon Health’s stance and applicable decision sources:
Surgical treatments (eg, UPPP, MMA) have evidence of benefit for adults who have failed or are intolerant/unaccepting of CPAP.
Recommendation informed by AASM task force evidence review (4 RCTs, 239 observational studies) and clinical judgment.
InterQual® criteria made available through Fallon’s Transparency Tool effective January 1, 2024.
When Medicare or MassHealth guidance governs, those criteria take precedence; Fallon may create internal criteria where Medicare/MassHealth criteria are not fully established.
Consult the member’s Evidence of Coverage for specific exclusions or limitations.
Procedure and diagnostic codes
| 21120 | Genioplasty; augmentation (autograft, allograft, or prosthetic material) |
| 21121 | Genioplasty; sliding osteotomy of a single piece |
| 21122 | Genioplasty; sliding osteotomies, including two or more osteotomies |
| 21123 | Genioplasty; wedge excision or bone wedge reversal for asymmetrical chin |
| 21141 | Reconstruction midface, LeFort 1; single piece, segment movement |
| 21142 | Reconstruction midface, LeFort 1; 2 pieces, segment movement |
| 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 |
| 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 |
Authorization and documentation requirements for providers
Prior authorization and medical necessity process
Prior authorization by a Fallon Health Medical Director is required for surgery for obstructive sleep apnea. For members 18 years and older, medical necessity determinations will use InterQual® Criteria effective for dates of service on or after January 1, 2026. Uvulopalatopharyngoplasty (UPPP) requires review by a Plan Medical Director; surgery for members under 18 will be reviewed case-by-case by a Plan Medical Director.
- Applies to Fallon Medicare Plus, MassHealth ACO, NaviCare HMO SNP, PACE, and Community Care products.
- InterQual® criteria are made available through Fallon’s Transparency Tool effective January 1, 2024.
Authorization and criteria sources
Fallon Health will use InterQual® Criteria for medical necessity determinations for surgery for obstructive sleep apnea for plan members age 18 and older effective for dates of service on or after January 1, 2026. Fallon Health follows applicable CMS NCDs/LCDs and MassHealth guidelines when making medical necessity determinations for respective members.
- Referenced InterQual® topics: Orthognathic Surgery for Obstructive Sleep Apnea (including maxillomandibular advancement, genioglossus advancement, hyoid myotomy/suspension) and Uvulopalatopharyngoplasty (UPPP).
- InterQual® criteria availability through Transparency Tool effective Jan 1, 2024.
- Policy history documents adoption effective Jan 1, 2026.
Clinical definitions and acronyms
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