Reference codes for PA requests

Reference codes to include with prior authorization requests: HCPCS codes for oral appliances and positional devices (E0486, E0485, E0530, A7049), custom oral appliance coding clarification (K1027), neurostimulation device and lead/pulse generator codes (L8679, L8680, L8686), CPT/HCPCS codes used for phrenic nerve stimulator programming and interrogation (93150, 93151, 93152, 93153), and implantation/nerve stimulator procedure codes (64582, 64583, 64584). Also consider procedure and device codes listed in the policy (0964T, 0965T, 0966T, 21142, 21199, 21206, 21685, 33276–33288, 41512, 41530, 41599, 42140, 42145, 42299, 64570, S2080, S2900) when applicable.

• E0486 (custom fabricated oral appliance)
• E0485 (prefabricated oral device)
• K1027 (custom oral device without fixed hinge)
• E0530 (electronic positional therapy)
• A7049 (EPAP valve)
• L8679 / L8680 / L8686 (implantable neurostimulator device/electrodes)
• 93150–93153 (phrenic nerve stimulator programming/interrogation)
• 64582–64584 (hypoglossal nerve neurostimulator implantation/revision/removal)
• 0964T–0966T (jaw expansion oral prosthesis codes)
• S2080, S2900 (LAUP, robotic surgery technique codes)

Prior authorization likely for hypoglossal nerve stimulator implantation

Implantation of a hypoglossal nerve stimulator (Inspire UAS) generally requires prior authorization; the policy frames HNS as a second-line, implantable surgical option for moderate-to-severe OSA in patients intolerant or unwilling to use PAP.

• Device is FDA‑approved Inspire UAS and is intended for patients unable or unwilling to use PAP
• HNS was evaluated as second‑line after PAP failure or intolerance in trials (STAR and others)

Prescribe custom, titratable oral appliances with documented follow-up

When prescribing oral appliance therapy (OAT), use custom, titratable devices fitted by a qualified dentist with documented follow-up and objective testing; the AASM and AADSM recommend physician-dentist collaboration and follow-up sleep testing to confirm efficacy.

• Face‑to‑face medical evaluation and diagnosis by a physician/APP required prior to OAT (AASM/AADSM/AAO‑HNS)
• Qualified dentist should fit a custom, titratable appliance rather than non‑custom devices
• Document follow‑up sleep testing and periodic collaborative visits between dentist and sleep physician

Authorization requires documented AHI and prior therapy

Authorization for implantable devices requires documentation of pre‑implant AHI (trial‑specific thresholds noted: remedē pivotal trial AHI ≥ 20; Inspire/STAR included moderate‑to‑severe OSA with median baseline AHI ~29) and documentation of prior guideline‑recommended therapy attempts (e.g., CPAP failure/intolerance).

• Provide attended polysomnography AHI supporting device inclusion threshold (e.g., remedē AHI ≥20; STAR median AHI ~29)
• Document prior PAP therapy and evidence of failure, intolerance, or refusal

Prior authorization documentation for remedē (implantable TPNS)

Prior authorization for implantable phrenic nerve neurostimulation (remedē) should document the CSA indication with baseline full‑night PSG AHI meeting trial criteria (pivotal trial required AHI ≥ 20), medical stability and prior appropriate guideline‑recommended therapy, and willingness to tolerate implantation and follow‑up per study-like inclusion.

• Baseline polysomnography demonstrating AHI ≥ 20 as used in the remedē pivotal trial
• Documentation of medical stability for ≥30 days and prior guideline‑recommended treatments
• Evidence of informed consent and capacity to comply with implantation and follow‑up procedures

Document prior noninvasive therapy attempts before invasive options

Providers must document trials and failure/intolerance of noninvasive therapies (CPAP or oral appliances) before surgery or implantable device consideration; guidelines (AASM, AAO‑HNS) indicate surgery is an option when noninvasive treatments have failed or are not tolerated.

• Record attempts and documented failure or intolerance of PAP and, when applicable, oral appliance therapy prior to surgical referral
• Include objective measures (PSG results) and clinical notes describing intolerance or non‑adherence

Confirm FDA indications and prior therapy in PA documentation

Prior authorization should confirm that the patient meets FDA‑labeled indications and guideline selection criteria for implantable or specialty devices (for example, Inspire UAS AHI/BMI limits and absence of complete concentric collapse), and that prior therapy attempts are documented.

• Verify AHI and BMI meet device labeling (Inspire original and expanded indications)
• Confirm absence of complete concentric palatal collapse (DISE) when required by device labeling
• Document prior PAP failure/intolerance

Verify member‑specific benefits and plan mandates

Verify member‑specific benefit plan terms and any applicable federal or state mandates before submitting authorization requests; the policy is intended to guide UnitedHealthcare standard plans but the member's plan governs coverage.

• Check the member specific benefit plan document for coverage rules and exclusions
• Be aware that medical records may be requested and that plan terms override the policy when conflicts exist

Document PAP trial before alternatives (OAT or surgery)

PAP therapy (CPAP/APAP) should be trialed and documented prior to offering alternatives like oral appliance therapy or surgical options; OAT may be considered when PAP shows no efficacy, intolerance, or patient refusal.

• Document therapeutic CPAP trial and objective efficacy data or documented intolerance/non‑adherence
• If offering OAT as alternative, include documentation of PAP failure/intolerance or patient refusal

Require CPAP trial before positional device coverage

Evidence shows CPAP more effectively reduces AHI than positional devices; payers may require a CPAP trial before coverage for positional therapy and positional devices are generally for position‑dependent OSA.

• Provide prior CPAP trial documentation when seeking coverage for positional devices
• Include PSG demonstrating position‑dependent OSA (non‑supine AHI criteria as applicable)

CPAP as first‑line; oral appliances for CPAP‑intolerant patients

Guidelines recommend CPAP/APAP as first‑line therapy for most adult OSA patients; oral appliances are an alternative for patients intolerant of CPAP or who prefer alternatives and should be prescribed and overseen by a sleep physician.

• Document CPAP/APAP prescription and trial results when applicable
• If using oral appliance as alternative, include diagnosis by sleep physician and dentist collaboration per AASM/AADSM guidance

HNS considered second‑line after PAP failure/intolerance

Hypoglossal nerve stimulation is presented and evaluated as a second‑line therapy after PAP failure or intolerance in multiple studies and guideline statements; authorization should reflect prior PAP attempts.

• Document prior PAP failure or intolerance and attempts to improve adherence
• Include trial‑like selection data (AHI/BMI, DISE findings) consistent with HNS candidacy

Attempt conservative therapy before surgical/implantable options

Noninvasive and guideline‑recommended therapies (e.g., CPAP/APAP) should be attempted and documented prior to consideration of surgical or implantable options; include objective testing and treatment notes.

• Provide PSG data and documentation of noninvasive therapy trials
• Include clinician notes describing intolerance, refusal, or inadequate efficacy

Surgery generally requires prior CPAP/oral appliance trial

Surgical interventions are typically considered second‑line after failure/intolerance of CPAP or oral appliance therapy per AASM and AAO‑HNS; prior conservative therapy documentation will be required for surgical authorization.

• Document prior CPAP and/or oral appliance trials and reasons for surgical consideration
• Include anatomical evaluation and procedure‑specific selection criteria for the planned surgery

Document therapy escalation steps and prior trials

Follow guideline-based escalation: consider mandibular advancement devices for mild‑to‑moderate OSA and evaluate hypoglossal nerve stimulation or surgery for selected patients who cannot adhere to PAP, ensuring documentation of prior trials.

• When escalating, document prior conservative therapy attempts and rationale for next‑line therapy
• Include objective PSG metrics and device‑specific candidacy data (AHI, BMI, DISE findings)

Face‑to‑face evaluation and documentation of PAP failure/intolerance required

Prior to devices or procedures, a face‑to‑face evaluation and diagnosis by a qualified sleep medicine physician (MD/DO) or APP under direct supervision is required; documentation of PAP failure/intolerance or refusal must be supplied when relevant.

• Include face‑to‑face visit notes, sleep physician diagnosis, and documentation of PAP failure/intolerance/refusal
• Medical records may be requested to determine medical necessity

Document collaborative care and follow‑up testing for OAT

For oral appliance therapy, document collaborative care between physician and dentist and record follow‑up sleep testing to confirm treatment efficacy per AASM and AADSM recommendations.

• Document referrals and communication between the sleep physician and qualified dentist
• Include results of follow‑up PSG or HSAT demonstrating efficacy or need for adjustment

Document medical diagnosis, dental collaboration, and follow‑up for OAT

Documentation for OAT should include a medical diagnosis of OSA by a qualified medical provider, referral to or collaboration with a qualified dentist for fitting, and objective follow‑up sleep testing to confirm efficacy.

• Medical diagnosis and recommendation from a physician or APP
• Dental fitting records and appliance specifications (custom, titratable)
• Follow‑up PSG/HSAT results and periodic dental/sleep clinic visits

Provide PSG‑confirmed AHI and prior CPAP documentation for device PA

Prior authorization should include polysomnography‑confirmed AHI and documentation of prior CPAP failure, intolerance, or refusal; device trials and implant studies consistently required these diagnostic data.

• Include attended PSG report with AHI and breakdown of central vs obstructive events
• Provide clinical notes documenting prior CPAP attempts and reasons for failure or intolerance

Clinical documentation required for remedē authorization

For implantable phrenic nerve neurostimulation (remedē), include baseline full‑night PSG AHI, documentation of prior guideline‑recommended therapy attempts, evidence of medical stability, and device implantation/follow‑up data in authorization materials.

• Baseline PSG AHI meeting trial criteria (e.g., AHI ≥20 in pivotal trial)
• Confirmation of prior guideline‑recommended therapies and medical stability ≥30 days
• Post‑implant follow‑up PSG and device interrogation/therapy programming notes

Document pre/post PSG, BMI, and DISE for tongue base procedures

For tongue base or lingual suspension procedures, include pre‑ and post‑operative PSG results, BMI, and drug‑induced sleep endoscopy findings when available; document prior CPAP intolerance and informed consent describing limited evidence and potential complications.

• Pre‑ and post‑op PSG reports and ESS scores
• BMI and DISE findings (if performed)
• Informed consent noting limited long‑term evidence and device/suture failure risks

Include objective pre/post PSG and validated symptom scores

When seeking authorization for surgical or device interventions, include objective pre/post documentation similar to published studies: pre‑ and post‑procedure polysomnography and validated symptom scores (e.g., ESS, NOSE) to demonstrate effect.

• Pre‑ and post‑procedure PSG data and comparison of AHI
• Validated symptom questionnaires (ESS, NOSE) before and after intervention

Document device‑specific FDA indication criteria are met

Demonstrate that device‑specific FDA indication criteria are met in authorization requests (for example, Inspire UAS AHI and BMI ranges, absence of complete concentric palatal collapse, and prior PAP failure/intolerance).

• Confirm AHI and BMI are within device labeling
• Provide DISE documentation excluding complete concentric collapse when required
• Show prior PAP failure/intolerance documentation

Check member‑specific plan precedence prior to authorization

Before using this policy for a coverage decision, check the member‑specific benefit plan document and any federal/state mandates; the member‑specific plan governs in case of conflict.

• Verify member benefit plan language and applicable mandates
• Prepare to supply medical records if requested for review

Coverage subject to member‑specific plan terms

Coverage is determined by the member‑specific benefit plan and applicable laws; inclusion of a service in this policy or the medical record documentation does not guarantee coverage.

• Be prepared to provide medical records for review
• Coverage decisions follow the member specific benefit plan and applicable law

Oral appliances for CSA lack evidence — risk of denial

Oral appliances are not supported for treatment of central sleep apnea (CSA); requests for OA to treat CSA may be denied due to lack of relevant evidence.

• Do not submit OA PA for CSA without strong supporting evidence — policy states no relevant evidence for OA in CSA

Unsupported devices (e.g., Slow Wave, ALF) may be denied

Devices without quality evidence (mandibular vertical repositioning devices, morning repositioning, epigenetic appliances, ALF) are unsupported and may be denied as not medically necessary.

• Avoid authorization for unsupported device classes; policy documents absence of quality evidence for these devices
• Provide literature support if asserting medical necessity for such devices

Missing prior therapy documentation may lead to denial

Lack of documentation of prior guideline‑recommended therapy (for example, CPAP failure or intolerance) is a common reason for coverage denial; ensure prior therapy trials are clearly recorded.

• Include notes on CPAP trial duration, adherence attempts, objective efficacy data, and reasons for discontinuation
• Document efforts to improve PAP adherence prior to declaring failure

Insufficient evidence for some procedures may trigger denial

Procedures lacking sufficient high‑quality evidence (for example, LAUP) may be denied or considered investigational; include strong supporting data if requesting coverage.

• Expect higher scrutiny and potential denial for LAUP and similar procedures with insufficient evidence
• Attach peer‑reviewed evidence and justification when requesting coverage for such procedures

Palatal implants — limited efficacy; denial risk

Palatal implants have limited and mixed evidence and some RCTs failed to show superiority over placebo; lack of demonstrated efficacy may prompt noncoverage or medical necessity review.

• Provide high‑quality evidence if requesting coverage for palatal implants; policy notes mixed results and limited effectiveness
• Be prepared to document patient selection consistent with cited trials (mild‑to‑moderate OSA, retropalatal obstruction)

Evidence limitations may lead to denial

Evidence gaps—such as few randomized trials, small sample sizes, short follow‑up, and bias—are cited as reasons that may lead to coverage denial for many procedures and devices lacking robust evidence.

• Anticipate denial or investigational determinations when evidence is low quality, biased, or lacks long‑term outcomes
• Supply robust comparative data when available to support a coverage request

Device indication constraints must be met or coverage may be denied

Confirm device indication constraints (e.g., Inspire UAS requires absence of complete concentric collapse at soft palate and prior PAP failure/intolerance); failure to meet these constraints may result in noncoverage.

• Provide DISE documentation and prior PAP trial evidence when seeking UAS coverage
• Ensure documented AHI/BMI are within device labeling

Member‑specific plan terms govern coverage — verify before PA

Member‑specific benefit plan terms govern coverage and may differ from this standard policy; verify plan language to avoid denied authorizations based on plan exclusions or differing criteria.

• Check member plan for exclusions or differing medical necessity criteria before submitting PA
• If conflict exists, the member specific benefit plan document governs