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UnitedHealthcare medical policy (Indiana only) defining coverage positions and referenced clinical criteria for non-surgical and surgical treatments of obstructive and central sleep apnea, listing proven (medically necessary) vs unproven/not medically necessary procedures/devices and applicable codes. This is part 1 of 4 and contains definitions, application, descriptions, evidence summaries, and code lists.
Added notation to indicate polysomnography should be repeated if there has been clinically significant weight loss or gain, changes in cardiovascular disease, or persistent or recurrent symptoms since the last study.
Revised language pertaining to medical necessity clinical coverage criteria for implantable hypoglossal nerve stimulation, including added reference to InterQual® criteria and clarified instruction to refer to InterQual Medicare WPS if medical necessity cannot be determined using the referenced InterQual criteria.
Added definition of 'Respiratory Disturbance Index (RDI)'.
Added CPT/HCPCS codes 0964T, 0965T, 0966T, and E0490 to Applicable Codes section.
Updated FDA and References sections to reflect the most current information.
This UnitedHealthcare medical policy applies only to the state of Indiana and defines coverage positions and referenced clinical criteria for treatments of obstructive and central sleep apnea. The policy addresses both obstructive sleep apnea (OSA) and central sleep apnea (CSA), covering non‑surgical and surgical options including removable oral appliances, implantable hypoglossal nerve stimulation, and other device- or procedure-based therapies. The overall coverage stance is mixed: certain therapies are considered medically necessary (for example, removable oral appliances for OSA in specified circumstances and several surgical procedures when criteria are met), while many devices and procedures — including a number of non‑surgical devices and implantable neurostimulation for CSA — are judged insufficient evidence / not medically necessary.
Application
Policy geographic application
Non-Surgical Treatment - Oral Appliances
Removable oral appliance coverage and cross-reference
Surgical Treatment - Medically Necessary Procedures for OSA
Medically necessary surgical procedures for OSA and cross-reference
Hypoglossal Nerve Stimulation (HNS)
Hypoglossal nerve stimulation (HNS) coverage and cross-reference
Implantable Neurostimulation for Central Sleep Apnea
Implantable neurostimulation for Central Sleep Apnea (CSA) — coverage conclusion
Polysomnography Repeat Criteria
Indications for repeat polysomnography (PSG)
Other Non-Surgical Procedures - Not Medically Necessary
The following are unproven and not medically necessary due to insufficient evidence of efficacy:
Not medically necessary determinations are based on limited, low‑quality, or conflicting evidence described in the policy's evidence reviews and narrative summaries — for many devices and procedures there are small, uncontrolled studies, short follow‑up, or inconsistent results, leaving safety and long‑term clinical benefit uncertain.
Reference InterQual criteria for coverage determination
Use the InterQual® CP criteria referenced in this policy to determine medical necessity for removable oral appliances and related procedure coverage decisions. The policy explicitly directs providers to the InterQual Durable Medical Equipment, Noninvasive Airway Assistive Devices criteria for oral appliances.
Prior authorization likely required for implantable devices and surgeries
Prior authorization is typically required for implantable devices and major surgeries. When seeking authorization, document prior therapies tried (e.g., CPAP intolerance or failure), clinical justification, and confirm device eligibility per device labeling and applicable InterQual procedure criteria.
Implantable neurostimulation (remedē) — investigational/conclusion of insufficient evidence
Coverage for implantable neurostimulation for Central Sleep Apnea (e.g., remedē) is limited by insufficient/very-low-quality evidence. Anticipate prior authorization requirements and be prepared to submit clinical evidence documenting expected benefit, prior treatments, and patient selection details.
Coverage risk for procedures with insufficient evidence
Procedures with limited or low-quality evidence (for example palatal implants, radiofrequency ablation, Distraction Osteogenesis for Maxillary Expansion (DOME), Transoral Robotic Surgery (TORS), and other procedures with heterogeneous or low-quality data) may be denied or considered investigational without adequate supporting documentation of medical necessity and appropriate patient selection.
Polysomnography repeat indications
Repeat polysomnography is recommended when clinically indicated — specifically after clinically significant weight loss or gain, changes in cardiovascular disease, or when there are persistent or recurrent symptoms since the last study.
HCPCS E0490 medical necessity review exception (Indiana)
HCPCS E0490 remains subject to the Indiana-specific billing exception: it is not managed for medical necessity review in Indiana. Providers should verify the current Prior Authorization and Notification List for UnitedHealthcare Community Plan of Indiana for any changes and for instruction on submitting claims.
Follow guideline-recommended diagnosis and specialist evaluation
Ensure a face-to-face evaluation and documented medical diagnosis of OSA by a qualified physician (otolaryngology or sleep medicine) before referring for dental/oral appliance therapy. Follow guideline recommendations for specialist evaluation and documented diagnosis prior to dental referral.
Oral appliance therapy follow-up and testing
Oral appliance therapy should be managed by a qualified dentist with ongoing oversight and include sleep-physician follow-up testing to confirm efficacy. Follow AASM and AADSM guidance to arrange follow-up sleep testing after appliance fitting and periodic joint follow-up visits.
Background and definitions in the policy include key terms such as Apnea‑Hypopnea Index (AHI), Body Mass Index (BMI), Central Sleep Apnea (CSA), Home Sleep Apnea Testing (HSAT), Obstructive Sleep Apnea (OSA), Oral Appliance, Polysomnogram (attended), and Respiratory Disturbance Index (RDI). Available treatments summarized include lifestyle modification, positional therapy, positive airway pressure (PAP) modalities, removable oral appliance therapy, electrostimulation devices, and various surgical options. The policy also notes that evidence is limited for several non‑surgical devices (e.g., nasal dilators, intranasal EPAP, positional devices, non‑surgical electrical muscle stimulation) and that implantable neurostimulation for CSA (transvenous phrenic nerve stimulation, e.g., remedē) currently has insufficient evidence of long‑term safety and clinical impact.
Coverage/Medical Necessity Conclusions in this Part
Findings and conclusions from evidence reviews and guidelines summarized for each therapy:
Key evidence highlights include the remedē randomized trial (Costanzo et al. 2016) showing a greater proportion of treated patients achieving ≥50% AHI reduction at 6 months versus control and longer‑term follow‑up reports with improvements at up to five years but with limitations of unblinded designs and incomplete follow‑up; laser‑assisted uvulopalatoplasty (LAUP) reviews showing mixed short‑term AHI changes but high complication rates and potential to worsen OSA; palatal implants and small RCTs with modest or inconsistent benefits and primarily short follow‑up; and radiofrequency ablation (RFA) and transoral robotic surgery (TORS) data largely from case series or low‑quality studies with heterogeneous results and limited long‑term evidence.
Added notation that polysomnography should be repeated if there has been clinically significant weight loss or gain, changes in cardiovascular disease, or persistent or recurrent symptoms since the last study. (material)
Revised language pertaining to medical necessity clinical coverage criteria for implantable hypoglossal nerve stimulation, including added reference to InterQual® CP: Procedures Hypoglossal Nerve Stimulation (HNS) and clarified instruction to refer to InterQual Medicare WPS if medical necessity cannot be determined using the referenced InterQual criteria. (material)
Added definition of 'Respiratory Disturbance Index (RDI)'. (non-material)
Added CPT/HCPCS codes 0964T, 0965T, 0966T, and E0490 to Applicable Codes section; noted HCPCS code E0490 is not managed for medical necessity review for the state of Indiana and to refer to the Prior Authorization and Notification List for UnitedHealthcare Community Plan of Indiana. (material)
Updated FDA and References sections to reflect the most current information; archived previous policy version CS116IN.16. (non-material)