ModifiedUnitedHealthcarePolicy N/A

Surgical treatments for obstructive sleep apnea (Orthognathic surgery, other surgical treatments, radiofrequency submucosal ablation)

Defines Medicare Advantage coverage guidance and applicable procedure/diagnosis codes for orthognathic surgery, other surgical treatments, and radiofrequency submucosal ablation for obstructive sleep apnea (OSA), and instructs compliance with applicable LCDs/LCAs or internal criteria (InterQual) where no LCD/LCA exists.

Policy Summary

PayerUnitedHealthcare

PolicySurgical treatments for obstructive sleep apnea (Orthognathic surgery, other surgical treatments, radiofrequency submucosal ablation)

Policy CodePolicy N/A

Change TypeRevised coverage guidance; archived prior version

Effective Date

Next Review Date

Key ActionRetain appropriate documentation to support coverage and submit accurate claims; documentation may be requested to support coverage determinations.

POLICY UPDATE CHANGES

Revised language pertaining to coverage guidelines for states/territories with no LCDs/LCAs; replaced reference to 'InterQual CP: Procedures, Maxillomandibular Advancement' with 'InterQual CP: Procedures, Orthognathic Surgery'.

9Referenced Procedure Codes

Coverage Summary

Defines Medicare Advantage coverage guidance and applicable procedure and diagnosis codes for orthognathic surgery, other surgical treatments, and radiofrequency submucosal ablation for obstructive sleep apnea (OSA). Coverage is determined by applicable Medicare NCDs/LCDs/LCAs where they exist, and where no local Medicare determination exists for the state/territory, coverage is determined using InterQual/internal criteria referenced in the policy. The listing of CPT codes in this policy is provided for reference only and does not imply coverage or guarantee reimbursement.

Medical Necessity / Applicability

Coverage Rationale / Applicability

Coverage and medical necessity are determined by compliance with applicable Medicare LCDs/LCAs where they exist; for states/territories with no LCD/LCA, UnitedHealthcare applies internal InterQual criteria referenced below.

Coverage determination follows one of

When a relevant Medicare NCD/LCD/LCA exists: If a relevant NCD, LCD or LCA exists for the procedure, compliance with that NCD/LCD/LCA is required.
When no Medicare NCD/LCD/LCA exists for the state/territory: If no applicable NCD/LCD/LCA exists for the state/territory, UnitedHealthcare will apply referenced internal criteria (InterQual CP: Procedures, Orthognathic Surgery for orthognathic procedures; or UnitedHealthcare Commercial Medical Policy titled Obstructive and Central Sleep Apnea Treatment for other procedures).

Referenced internal criteria: InterQual CP: Procedures, Orthognathic Surgery (for orthognathic procedures) and UnitedHealthcare Commercial Medical Policy titled Obstructive and Central Sleep Apnea Treatment (for other procedures) are the criteria applied when no LCD/LCA exists.

Coding

Orthognathic Surgery for the Treatment of Obstructive Sleep Apnea (OSA) - referenced CPT procedure codesCPT

21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction, without bone graft
21145	Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

Other Surgical Treatments for OSA - referenced CPT procedure codesCPT

21199	Osteotomy, mandible, segmental; with genioglossus advancement
21685	Hyoid myotomy and suspension
41512	Tongue base suspension, permanent suture technique
41599	Unlisted procedure, tongue, floor of mouth
42145	Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Radiofrequency Submucosal Ablation of the Soft Palate and/or Tongue Base - referenced CPT codeCPT

41530

Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session

Related/Referenced Medicare LCDs/LCAsmixed

L34526	Surgical Treatment of Obstructive Sleep Apnea (OSA) - LCD reference
A56905	Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA) - LCA reference

Provider Actions & Billing Guidance

Documentation Required

Retain documentation to support coverage

Providers are expected to retain or have access to appropriate documentation to support coverage and to submit accurate claims; documentation may be requested to support coverage determinations.

Prior Authorization

Follow applicable LCD/LCA or delegate authorization requirements

If a delegate manages utilization management and authorization requirements for a member's plan, the delegate's authorization requirements must be followed; where LCDs/LCAs apply, compliance with those policies is required.

Billing Rule

Coding guidance is for reference and does not guarantee payment

Listing of CPT codes in the policy is for reference only and does not imply coverage or guarantee reimbursement; benefit coverage is determined by the member-specific benefit plan document and applicable laws.

21141
21145
21196
21199
21685
41512
41599
42145
41530

Background

This Medicare Advantage policy provides guidance to support UnitedHealthcare coverage decisions for surgical treatments of obstructive sleep apnea (OSA). When local Medicare coverage (NCD/LCD/LCA) exists for a procedure, providers and plans should follow those determinations; for states or territories with no applicable LCD/LCA, UnitedHealthcare applies referenced internal criteria (such as InterQual CP: Procedures, Orthognathic Surgery) or the UnitedHealthcare Commercial Medical Policy titled Obstructive and Central Sleep Apnea Treatment for other procedures to guide coverage decisions.

InterQual CP: Procedures, Orthognathic Surgery — Internal UnitedHealthcare clinical criteria referenced for orthognathic surgery when no LCD/LCA exists.

Type	Number	Name	Effective Date
LCD	L34526	Surgical Treatment of Obstructive Sleep Apnea (OSA)
LCA	A56905	Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)

Revision History

06/01/2025revisedLatest

Revised language pertaining to coverage guidelines for states/territories with no Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs); replaced reference to 'InterQual CP: Procedures, Maxillomandibular Advancement' with 'InterQual CP: Procedures, Orthognathic Surgery'. Archived previous policy version MMPO87; updated supporting information and references. (has material change: true). Detail: Archived previous policy version MMPO87; updated supporting information and references. Note: this change corresponds to the policy status MODIFIED and the document has has_material_change = true in the brief provided. Detail field: Archived previous policy version MMPO87; updated supporting information and references. (See supporting source for exact wording and revision summary.)