CurrentUnitedHealthcarePolicy CS116ID.B

Obstructive and Central Sleep Apnea Treatment (for Idaho Only)

UnitedHealthcare medical policy CS116ID.B for Idaho (including Idaho Medicaid Plus) defines coverage and medical necessity criteria for non-surgical and surgical treatments of obstructive and central sleep apnea, lists unproven/not medically necessary devices and procedures, documentation requirements, definitions, background, evidence summaries, and applicable procedure/HCPCS/CPT/other codes (part 1 of 5).

Policy Summary

PayerUnitedHealthcare

PolicyObstructive and Central Sleep Apnea Treatment (for Idaho Only)

Policy CodePolicy CS116ID.B

Change TypeDocumentation requirement added (medical records)

Effective DateApr 1, 2026

Next Review Date

Key ActionProvide and maintain legible medical records that document face-to-face evaluation, diagnosis, prior PAP trial/failure or intolerance, diagnostic test results, and other information to support medical necessity and make them available upon request.

POLICY UPDATE CHANGES

Added language specifying medical record documentation requirements to support medical necessity for requested services.

mixedOral appliance stance (mixed)

conditionalNeurostimulation coverage (conditional)

not coveredCSA neurostimulation

lowOverall evidence quality for many novel devices

126STAR trial participants

1Material policy revision on 2026-04-01

Coverage Summary & Scope

UnitedHealthcare Medical Policy CS116ID.B (effective April 1, 2026) applies to Idaho (including Idaho Medicaid Plus) and provides coverage and medical necessity criteria for treatments of Obstructive Sleep Apnea (OSA) and Central Sleep Apnea (CSA). Coverage stance is mixed: some non‑surgical and surgical therapies are covered when criteria are met (examples: custom, titratable oral appliances for OSA; select surgeries; implantable hypoglossal nerve stimulation for adults and certain adolescents), while many novel devices and procedures are considered unproven / not medically necessary (examples: positional devices, nasal dilators, intranasal EPAP valves, removable oral appliances for CSA, many prefabricated or novel oral devices). The policy lists device- and procedure-specific thresholds used to determine eligibility (e.g., AHI ≥ 15 for moderate OSA; hypoglossal stimulation adults AHI ≥ 15 and ≤ 100 with BMI ≤ 40 kg/m2; adolescent Down syndrome criteria AHI ≥ 10 and RDI ≤ 50), and documents required medical-record evidence to support medical necessity. Stats summary: mixed oral appliance stance (custom supported, prefabricated not); multiple surgical procedures conditionally covered; implantable hypoglossal stimulation conditionally covered for adults and select adolescents; implantable neurostimulation for CSA not covered / unproven.

Key threshold values

AHI/RDI for moderate OSA≥ 15 events/hour

AHI for adult hypoglossal stimulation (PSG attended)≥ 15 and ≤ 100 events/hour

Total central + mixed apneas limitTotal AHI < 25% for central + mixed apneas

ESS threshold for excessive sleepinessEpworth Sleepiness Scale (ESS) > 10

Adolescent Down syndrome hypoglossal stimulationAHI ≥ 10 and RDI ≤ 50 events/hour; BMI < 95th percentile for age; PSG within 24 months

BMI limit for hypoglossal stimulation (adults)≤ 40 kg/m2

Responder / surgical success definition (studies)≥ 50% reduction in AHI and postoperative AHI < 20 events/hour

Inclusion AHI examples citedRanges referenced: AHI ≥ 5 (mild), 15–30 (moderate), >30 (severe); remedē inclusion AHI ≥ 20

ESS study inclusion noteSome studies used ESS ≥ 8 for inclusion; ESS reported baseline/post-treatment

Medical Necessity Criteria

Removable Oral Appliances (Non-surgical) - Medical Necessity

Removable oral appliances (non‑surgical) are considered medically necessary for the treatment of Obstructive Sleep Apnea (OSA) when ALL of the following are met:

ALL of the following

Documented diagnosis of OSA based on a valid sleep study (Polysomnography or Home Sleep Apnea Testing) as defined in this policy.
A face-to-face evaluation by a qualified physician (MD or DO) trained in sleep medicine or an advanced practice provider (APP) working under the direct supervision of a sleep medicine physician prior to initiation of oral appliance therapy.
A treating physician (MD or DO) or APP has diagnosed OSA and recommended oral appliance therapy as appropriate treatment.
Prior trial of positive airway pressure (PAP) therapy with documentation of therapeutic failure, intolerance, or patient refusal, unless PAP is contraindicated or not appropriate for the individual patient.

Not Medically Necessary / Experimental Devices & Procedures

The policy explicitly states the coverage stance that implantable neurostimulation devices for treatment of Central Sleep Apnea (CSA) are unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. Providers should note denial risk guidance in Provider Actions: document objective clinical rationale and required prior treatments, and be aware that procedures with insufficient evidence may be non‑covered unless robust supporting documentation is provided.

Relevant Codes (HCPCS, CPT, Other)

Surgical / CPT / Procedure codes referencedCPT

21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft
21199	Osteotomy, mandible, segmental; with genioglossus advancement
21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21685	Hyoid myotomy and suspension
33276	Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s])
33277	Insertion of phrenic nerve stimulator transvenous sensing lead (list separately)
33278	Removal of phrenic nerve stimulator, system including pulse generator and lead(s)
33279	Removal of phrenic nerve stimulator; transvenous stimulation or sensing lead(s) only
33280	Removal of phrenic nerve stimulator; pulse generator only
33281	Repositioning of phrenic nerve stimulator transvenous lead(s)

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Provider Actions — Prior Auth, Documentation, Billing

Prior Authorization

Prior Authorization Required for Advanced Therapies

Selection of advanced procedures or devices (including novel or recently introduced technologies) may require prior authorization. Special arrangements and guidance per NICE or equivalent health-technology guidance should be followed when applicable.

Prior authorization required for implantable hypoglossal nerve stimulation and other advanced device therapies when criteria must be confirmed.
Use of third-party prior authorization tools and vendor portals may be required for submission and review.

Documentation Required

Face-to-Face Evaluation Required Before OAT

A face-to-face evaluation with a qualified Physician (MD or DO) trained in sleep medicine or an Advanced Practice Provider under direct supervision of a sleep medicine Physician is required before initiating Oral Appliance Therapy (OAT).

Background, Evidence Summaries & Definitions

Background: OSA is characterized by recurrent collapse or obstruction of the upper airway during sleep, producing apneas and hypopneas with associated symptoms (e.g., excessive daytime sleepiness, loud snoring) and physiological sequelae. CSA results from loss or reduction of respiratory drive. Diagnosis uses Polysomnography (PSG, attended) or Home Sleep Apnea Testing (HSAT; adequate HSAT ≥ 4 hours with specified sensors). Conservative treatments include lifestyle measures, positional therapy, PAP (CPAP/APAP/BiPAP), and oral appliance therapy (MAD/OAT). Surgical options include UPPP, mandibular osteotomy, maxillomandibular advancement (MMA), and other upper‑airway procedures. Device descriptions in the policy cover nasal dilators, intranasal EPAP valves, positional devices, noninvasive electrical muscular stimulation (eXciteOSA), and implantable hypoglossal nerve stimulators (e.g., Inspire). The policy cites evidence assessments for positional devices, nasal dilators, and EPAP devices and summarizes that these have limited or low‑quality evidence supporting efficacy.

Evidence source	Key conclusion
AASM position (Ramar et al., 2015)	Recommends collaboration between dentists and physicians for oral appliance therapy with follow-up sleep testing; supports custom, titratable appliances over non-custom in adults; oral appliances considered when CPAP intolerant
Hayes assessments (NightBalance; eXciteOSA; remedē)	Hayes finds low-to-very-low quality evidence for positional devices and eXciteOSA; for remedē (PNS) evidence limited/insufficient to draw definitive clinical conclusions though some RCTs show improvements
Cochrane (Srijithesh et al., 2019) / Positional therapy reviews (Barnes et al., 2017)	Positional therapy may improve short-term adherence but CPAP is superior for AHI reduction; overall evidence low-to-moderate and short-term
STAR trial (Strollo et al., 2014; STAR analyses)	In HNS STAR cohort (n=126) median AHI decreased 68% (29.3 → 9.0 events/hr) and ODI decreased 70% (25.4 → 7.4) at 12 months, with sustained benefits in follow-ups
remedē pivotal trial (Costanzo et al., 2016) and PAS (Costanzo et al., 2021)	In randomized remedē TPNS pivotal trial (n=151) at 6 months 51% of treatment group achieved ≥50% AHI reduction vs 11% control (difference 41%, 95% CI 25–54, p<0.0001); long-term PAS shows improvements but evidence judged limited
EPAP / Provent trials (Berry 2011; Kryger 2011; Walsh, Rosenthal, Colrain)	Randomized and extension studies show short-term reductions in AHI and ESS and high adherence in responders (eg, Berry: device-on AHI reduction 52.7% week1; Kryger 12-month cohort median AHI reduced 71.3% in analyzable responders), but studies limited by design, small samples, and manufacturer sponsorship
Nasal dilator meta-analysis (Camacho et al., 2016) and individual studies	Meta-analysis found most studies showed no significant change in AHI with internal or external nasal dilators; overall no clear OSA benefit
Meta-analyses / systematic reviews for positional devices and SPT (de Ruiter et al., 2018) and Hayes/ECRI reports	Sleep position trainer trials show AHI and ODI reductions similar to oral appliance in some studies at 3–12 months but higher dropout rates and short-term data; Hayes/ECRI conclude evidence inconclusive or low quality
RCT: Prefabricated vs custom MAD (Johal et al., 2017)	Custom mandibular advancement devices are superior to ready-made devices for AHI reduction in small RCT (n=35) with limitations
eXciteOSA evidence (Hayes, ECRI, Moffa, Kotecha, Baptista)	Single-arm and pre-post studies show small AHI/ODI/snoring improvements in mild OSA/snoring but evidence quality very low; conclusions inconclusive
Guideline & technology assessments (AASM, AAO-HNS, ERS, NICE, AHRQ summaries)	Guidelines generally recommend CPAP first; oral appliances supported for mild-moderate OSA or CPAP intolerance; HNS considered for select CPAP-intolerant patients with specified criteria; many novel devices have low-quality evidence
Remedē meta-analyses and reviews (Wang et al., 2023; ECRI summaries)	Systematic reviews/meta-analyses of PNS/TPNS show reductions in AHI/CAI but evidence limited; further RCTs and long-term data needed

Key definitions (glossary): AHI: Apnea‑Hypopnea Index — events/hour (thresholds commonly used: ≥ 15 = moderate‑to‑severe). ESS: Epworth Sleepiness Scale — an 8‑item questionnaire; ESS > 10 denotes excessive daytime sleepiness. HSAT: Home Sleep Apnea Testing — unattended testing; adequate HSAT is ≥ 4 hours and includes nasal pressure, respiratory effort bands, and oximetry. EPAP: Expiratory Positive Airway Pressure intranasal valve devices (e.g., Provent/Bongo). MAD/OAT: Mandibular Advancement Device / Oral Appliance Therapy — custom, titratable devices retain the lower jaw forward to maintain airway patency. HNS/UAS: Hypoglossal Nerve Stimulation / Upper Airway Stimulation — implantable systems (e.g., Inspire) that stimulate the hypoglossal nerve to advance the tongue. MMA: Maxillomandibular Advancement — orthognathic surgery to enlarge the airway. DISE: Drug‑Induced Sleep Endoscopy — endoscopic evaluation under sedation to assess collapse patterns (used to exclude concentric palatal collapse prior to HNS).

FDA Indications & Device-Specific Statements (Informational)

Informational FDA/device statements summarized: Inspire Upper Airway Stimulation (PMA P130008) — PMA originally indicated for adults with AHI ≥ 20 and ≤ 65; FDA expanded indications (2023) to allow lower AHI limits (≤ 15), higher baseline AHI up to 100, and higher BMI up to 40 kg/m2, and pediatric expansion for certain adolescents with Down syndrome. remedē System (PMA P160039) — implantable phrenic nerve stimulator for moderate‑to‑severe CSA in adults. eXciteOSA (DEN200018) — de novo device for removable tongue stimulation for snoring and mild OSA (AHI < 15). Slow Wave DS8 (K191320) — 510(k) for snoring/mild–moderate OSA. Coblation and Somnoplasty (510(k) devices) — approved for tissue ablation/ENT surgery. AIRvance (Repose) tongue suspension (K981677) and Pillar palatal implants (K040417) — cleared 510(k) devices for tongue suspension and palatal implants respectively. The policy emphasizes that FDA clearance/approval is informational only — FDA status alone does not determine coverage.

Medicare Local Coverage Determinations

Name	Number	Effective Date
Transvenous Phrenic Nerve Stimulation in the Treatment of Central Sleep Apnea	L37929

Medical Records & Documentation Requirements

Documentation Required

Policy change — medical record documentation requirements (04/01/2026)

Material policy change on 04/01/2026: added language specifying that the patient's medical record must contain documentation that fully supports the medical necessity for requested services. Documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Date of change: 04/01/2026.
Requirement: medical records must fully support medical necessity and be available upon request.

Revision History

2026-04-01material_changeLatest

Archived previous policy version CS116ID.A and added language specifying medical record documentation requirements: the patient's medical record must contain documentation that fully supports medical necessity (including relevant medical history, physical exam, and diagnostic test/procedure results), documentation must be legible, maintained in the medical record, and made available upon request.

Policy Summary

PayerUnitedHealthcare

PolicyObstructive and Central Sleep Apnea Treatment (for Idaho Only)

Policy CodePolicy CS116ID.B

Change TypeDocumentation requirement added (medical records)

Effective DateApr 1, 2026

Next Review Date

On This Page

Fitting, fabrication, and titration of a custom, removable oral appliance performed by qualified dental/sleep professionals per established standards (prefabricated devices are not considered medically necessary).

Clinical documentation supports expected benefit from oral appliance therapy (e.g., symptom improvement, ESS, or other validated measures).

Exclusions/Not Medically Necessary

Removable oral appliances for treatment of Central Sleep Apnea are NOT medically necessary.
Prefabricated (ready‑made) oral appliances or devices that are not custom‑fabricated are NOT medically necessary.

Operational Note

Refer to the InterQual CP: Durable Medical Equipment, Noninvasive Airway Assistive Devices criteria for detailed device-level clinical criteria and coding guidance.

Provider Actions

Face-to-face evaluation and documentation of PAP trial or intolerance must be present in the medical record prior to authorization of a removable oral appliance.

Callout

Prior authorization may be required by the plan; submit complete sleep study reports, ESS results, PAP trial documentation, and dental fitting records.

Surgical procedures proven and medically necessary (UPPP, MO, MMA)

The following surgical procedures are considered proven and medically necessary for treatment of OSA when the procedure-specific criteria below are met. ALL primary criteria must be satisfied and then the applicable procedure-specific additional criteria apply.

ALL of the following

Diagnosis of moderate to severe OSA, defined as AHI or RDI ≥ 15 events/hour (Polysomnography).
Excessive daytime sleepiness documented by an Epworth Sleepiness Scale (ESS) > 10 or another validated measure of sleepiness.
Documented trial of PAP therapy that resulted in no therapeutic efficacy, or documentation of PAP intolerance or patient refusal.

Procedure-specific additional criteria (select applicable procedure)

Maxillomandibular osteotomy and advancement (MMA)
- Evidence of craniofacial disproportion or deformity with maxillomandibular deficiency documented by clinical and radiographic evaluation.
Mandibular osteotomy (MO)
- Evidence that the primary site of obstruction is retrolingual or lower pharyngeal region (e.g., clinical exam, endoscopy imaging) supporting MO.
Uvulopalatopharyngoplasty (UPPP)
- Anatomical site of obstruction appropriate for UPPP (e.g., velopharyngeal collapse) as determined by clinical assessment or endoscopic evaluation.

Operational Note

Procedures not listed above or lacking patient-specific anatomic indication should be considered unproven/not medically necessary unless supported by high-quality evidence and plan coverage rules.

Provider Actions

Submit preoperative sleep study results, ESS score or equivalent, documentation of PAP trial/failure/intolerance, and procedure-specific anatomic evaluations (e.g., imaging, endoscopy).

Implantable hypoglossal nerve stimulation (Adults)

Implantable hypoglossal nerve stimulation (HNS) with an FDA‑approved device is considered proven and medically necessary in adults with moderate to severe OSA when ALL of the following criteria are met:

ALL of the following

Age ≥ 18 years (adult).
Body Mass Index (BMI) ≤ 40 kg/m2.<= 40 kg/m2
AHI ≥ 15 and ≤ 100 events/hour as determined by attended polysomnography.15-100
Central and mixed apneas comprise < 25% of total AHI.< 25%
Absence of complete concentric collapse at the level of the soft palate on drug-induced sleep endoscopy (DISE) or other validated assessment.
Documented trial of PAP therapy that resulted in no therapeutic efficacy, intolerance, or patient refusal, unless PAP is contraindicated.
Device implanted and used in accordance with FDA labeling and manufacturer instructions, including any pre-implant testing and follow-up requirements.

FDA Guidance / Device-specific statements (Informational)

Only FDA‑approved HNS systems with indications matching the patient profile should be considered for coverage; follow manufacturer labeling for contraindications and testing (e.g., DISE requirement).
Coverage decisions may consider device-specific clinical trial evidence, manufacturer-specified patient selection testing, and required follow-up programming and monitoring as part of medical necessity determination.

Exclusions/Not Medically Necessary

HNS is NOT medically necessary when BMI > 40 kg/m2, AHI outside 15–100, central/mixed apneas ≥ 25% of total AHI, or complete concentric palatal collapse is present.

Implantable hypoglossal nerve stimulation (Adolescents with Down syndrome)

Implantable hypoglossal nerve stimulation (HNS) with an FDA‑approved device is considered proven and medically necessary in adolescents (age 10–18 years) with Down syndrome when ALL of the following FDA-aligned criteria are met:

ALL of the following

Age between 10 and 18 years at time of implant (inclusive).
Confirmed diagnosis of Down syndrome.
Polysomnography within 24 months demonstrating OSA with AHI ≥ 10 events/hour and RDI ≤ 50 events/hour (severe OSA by policy definitions).AHI >=10
BMI < 95th percentile for age (per CDC growth charts) at time of evaluation.
Use age-and-sex percentiles for BMI.
Central and mixed apneas comprise < 25% of total AHI.< 25%
Contraindication to, or ineffective treatment with, prior adenotonsillectomy when clinically indicated.
Documented failure or intolerance of PAP therapy despite attempts to improve adherence and support.
No tracheostomy use during sleep.
Absence of complete blockage or concentric collapse of the soft palate confirmed by DISE (medication‑induced sleep endoscopy).
Individual and caregiver refusal of MMA for non‑concentric palatal collapse or when MMA contraindicated or not appropriate.
Device implanted and used in accordance with FDA labeling and manufacturer instructions for the adolescent Down syndrome indication.

FDA Guidance / Device-specific statements (Informational)

Use only devices with FDA clearance/approval that include the adolescent Down syndrome indication; follow all manufacturer pre-implant testing, DISE protocols, and post-implant follow-up requirements.
Documentation should include current growth percentiles, recent polysomnography results, DISE findings, and records of PAP trials and adenotonsillectomy status.

Coverage / Medical Necessity Conclusions (implied from evidence summaries)

Coverage / Medical Necessity Conclusions — evidence-based guidance and device-specific statements to inform coverage interpretation:

ALL of the following

Implantable hypoglossal nerve stimulation (HNS) for appropriately selected adults (per criteria above) and for adolescents with Down syndrome (per criteria above) has demonstrated efficacy in clinical trials and is considered medically necessary when selection criteria and FDA labeling are met.
Removable custom oral appliances are demonstrated effective for OSA and are considered medically necessary for obstructive (not central) sleep apnea when clinical and device criteria are satisfied.
Implantable neurostimulation devices for the treatment of Central Sleep Apnea (CSA) are considered investigational/unproven and NOT medically necessary due to insufficient evidence of safety and efficacy.
Certain other surgical and non‑surgical procedures and devices (listed elsewhere in this policy) lack sufficient evidence and are considered unproven/not medically necessary; see policy exclusions for specifics.

Device/therapy evidence summary (guidance)

HNS: Randomized and observational studies support reduction in AHI and symptom measures in selected adult populations; device-specific FDA approvals and labeling should guide patient selection.
Oral appliances: Systematic reviews and practice guidelines support custom mandibular advancement devices for mild-to-moderate OSA and for patients intolerant of PAP; prefabricated devices lack sufficient evidence.
Neurostimulation for CSA: Current evidence is limited and inconsistent; therefore such devices remain unproven for routine coverage.

FDA Indications and Device-Specific Coverage-Relevant Statements (Informational criteria)

Additional informational and FDA/device‑specific statements relevant to coverage determinations (informational criteria):

ALL of the following

FDA indications, device labeling, and manufacturer instructions are informationally important and must be followed; coverage for FDA‑approved indications is favored when clinical criteria align with labeling.
DISE (drug‑induced sleep endoscopy) findings, when required by device labeling (e.g., to rule out complete concentric palatal collapse), are essential documentation for HNS candidacy.
PAP failure/intolerance should be well‑documented, including duration, settings, adherence attempts, and interventions to improve tolerance (mask fitting, pressure adjustments, desensitization, or behavioral supports).
For adolescent candidates, pediatric-specific considerations (growth percentiles, surgical history such as adenotonsillectomy) and caregiver consent must be documented in the medical record prior to authorization.
Implantable neurostimulation devices for CSA: note that absence of sufficient evidence is the basis for noncoverage; clinical trial enrollment or investigational pathways may be appropriate alternatives.

Provider Actions / Documentation Required

Submit complete attended polysomnography reports (scored AHI components), DISE reports if performed, ESS or other sleepiness measures, detailed PAP trial documentation, surgical/anatomic evaluations, and device-specific testing as indicated by manufacturer labeling.
Medical records must fully support medical necessity; lack of required documentation may lead to denial of coverage.

Operational Note

This section consolidates device-level evidence and FDA-aligned instructions to assist clinical reviewers; it does not replace detailed manufacturer labeling or the plan's prior authorization processes.

Face-to-face evaluation required prior to OAT initiation.
Diagnosis and treatment recommendation must be documented by the treating Physician (MD or DO) or supervising Advanced Practice Provider.

Documentation Required

Diagnosis and Recommendation Documentation

Diagnosis of OSA and the recommended course of treatment must be documented in the medical record by the treating Physician (MD or DO) or an Advanced Practice Provider (under supervision). Medical records supporting clinical decisions must be legible and made available upon request.

Document clinical history, physical exam findings, diagnostic test results, and rationale for chosen therapy.
If PAP therapy was attempted, provide documentation of therapeutic efficacy testing or documented intolerance/refusal.

Documentation Required

Polysomnography Requirement and Baseline/Follow-Up Testing

Polysomnography (attended) or appropriate sleep testing is required to establish the severity of OSA for certain treatments and surgical eligibility. Baseline and follow-up sleep testing requirements apply to multiple therapies.

A diagnostic polysomnogram (attended) is required when referenced in surgical or device criteria (e.g., AHI thresholds for UPPP, MMA, hypoglossal nerve stimulation).
Baseline polysomnography must be available for review when determining candidacy; follow-up polysomnography is required after certain interventions to assess efficacy.

Documentation Required

Drug-Induced Sleep Endoscopy (DISE) for Candidate Selection

Drug-induced sleep endoscopy (DISE) may be required to confirm anatomy and identify candidates for specific surgical or device procedures (for example, to confirm absence of complete concentric collapse at the soft palate prior to hypoglossal nerve stimulation or to evaluate pediatric surgical candidates).

Document DISE findings in the medical record when used to determine candidacy for implantable devices or surgery.
Include video or procedural report and interpretation in the member's chart.

Prior Authorization

CPAP Trial and Intolerance Documentation

Prior authorization is required when PAP therapy has failed, is not tolerated, or refused, before approval of alternative therapies such as OAT or surgical options; documentation of CPAP trial and documented intolerance or inadequate therapeutic response must be provided.

Provide records of CPAP titration, adherence attempts, troubleshooting efforts, and reasons for intolerance/refusal.
If CPAP produced no therapeutic efficacy, include objective testing or clinician documentation supporting that conclusion.

Prior Authorization

Guideline-Directed Selection and Documentation

Use guideline-directed selection and document application of applicable clinical guideline criteria (e.g., AASM, AAO-HNS, AADSM, InterQual) when selecting candidates for therapies and devices. Documentation must show how the member meets each required criterion.

Cite the guideline used and map member findings to each required criterion for coverage decisions.
Include objective measures (AHI/RDI, ESS scores, BMI thresholds) and prior therapy history.

Prior Authorization

Special Arrangements for Novel Procedures/Devices

Special arrangements per external guidance (e.g., NICE) may apply for novel procedures or devices; prior authorization submissions should reference any such guidance and provide required additional evidence or outcomes reporting when requested.

When NICE or similar guidance specifies special data collection or outcome reporting, include those plans in the authorization request.
Failure to provide required external- guidance documentation may delay or deny coverage.

Denial Risk

Denial Risk for Procedures with Insufficient Evidence

Procedures or devices deemed unproven due to insufficient evidence of efficacy are subject to non-coverage. Providers should be aware these items carry a high denial risk if medical necessity criteria are not met.

Examples include positional OSA devices, certain oral appliances for central sleep apnea, palatal implants, LAUP, lingual suspension, transoral robotic surgery, and other listed unproven procedures.
If a service is determined investigational or unproven, coverage will likely be denied.

Documentation Required

Medical Record Documentation Required for Reviews

Medical record documentation must be maintained and made available for review to substantiate medical necessity decisions. Records should include all diagnostic studies, procedural reports (including DISE), CPAP trial documentation, and follow-up sleep testing results.

Maintain baseline and post-treatment polysomnography or HSAT reports when required for ongoing coverage or efficacy assessment.
Provide complete medical records upon request to facilitate authorization and retrospective review.

Billing Rule

Billing and Coding Rules

Billing and coding rules apply; providers must follow payer billing guidance and exclude dental codes where indicated. Clarify HCPCS/HCPCS-level coding questions with the payer prior to submission.

Do not bill dental CDT codes for medical services covered under this policy.
Clarify HCPCS code use for oral appliances and durable medical equipment with UnitedHealthcare billing guidance.