CurrentUnitedHealthcarePolicy CS116IN.17

Obstructive and Central Sleep Apnea Treatment (for Indiana Only)

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.

Policy Summary

PayerUnitedHealthcare

PolicyObstructive and Central Sleep Apnea Treatment (for Indiana Only)

Policy CodePolicy CS116IN.17

Change TypeCodes addedHNS criteria reviseddefinitions updated

Effective DateNov 1, 2025

Next Review Date

Key ActionRefer to the InterQual clinical criteria referenced in the policy to determine medical necessity for removable oral appliances, surgical procedures, and hypoglossal nerve stimulation; repeat polysomnography when clinically indicated.

SourceLink

POLICY UPDATE CHANGES

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.

4Codes Added in Revision

ManyInsufficient evidence categories

SomeMedically necessary surgical procedures

remedēImplantable neurostimulation highlighted

1Indiana-specific billing exception (E0490)

Coverage Summary

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.

Quick reference — HSAT adequacy and OSA severity thresholds

HSAT adequacyAdequate HSAT = minimum 4 hours with nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry

OSA severity - MildAHI or RDI ≥ 5 and < 15 events/hour

OSA severity - ModerateAHI or RDI ≥ 15 and ≤ 30 events/hour

OSA severity - Severe

Policy Summary

PayerUnitedHealthcare

PolicyObstructive and Central Sleep Apnea Treatment (for Indiana Only)

Policy CodePolicy CS116IN.17

Change TypeCodes addedHNS criteria reviseddefinitions updated

Effective DateNov 1, 2025

Next Review Date

SourceLink

On This Page

Medical Necessity Criteria

Application

Policy geographic application

This Medical Policy only applies to the state of Indiana.

Non-Surgical Treatment - Oral Appliances

Removable oral appliance coverage and cross-reference

Removable Oral Appliances are proven and medically necessary for treatment of Obstructive Sleep Apnea (OSA) when clinical criteria are met. For medical necessity clinical coverage criteria for removable Oral Appliances, refer to the InterQual® CP: Durable Medical Equipment, Noninvasive Airway Assistive Devices.

Refer to the InterQual® CP: Durable Medical Equipment for specific clinical criteria and requirements (including documentation and prior authorization where applicable).

Surgical Treatment - Medically Necessary Procedures for OSA

Medically necessary surgical procedures for OSA and cross-reference

ANY of the following surgical procedures are proven and medically necessary for treating OSA as documented by Polysomnography when InterQual criteria are met:

• Maxillomandibular Advancement

• Osteotomy, Anterior Segment, Mandible

• Uvulopalatopharyngoplasty (UPPP)

If medical necessity cannot be determined using these criteria, refer to the InterQual® Medicare: Procedures, Surgical Treatment of Obstructive Sleep Apnea (OSA) WPS.

Hypoglossal Nerve Stimulation (HNS)

Hypoglossal nerve stimulation (HNS) coverage and cross-reference

Implantable hypoglossal nerve stimulation (HNS) is medically necessary in certain circumstances when InterQual® CP: Procedures Hypoglossal Nerve Stimulation criteria are met.

If medical necessity cannot be determined using these criteria, refer to the InterQual® Medicare: Procedures, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea WPS.

Implantable Neurostimulation for Central Sleep Apnea

Implantable neurostimulation for Central Sleep Apnea (CSA) — coverage conclusion

Implantable neurostimulation devices for the treatment of Central Sleep Apnea (CSA) are unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

Polysomnography Repeat Criteria

Indications for repeat polysomnography (PSG)

Polysomnography should be repeated if there has been clinically significant weight loss or gain, changes in cardiovascular disease, or there are persistent or recurrent symptoms since the last study (Caples et al. 2021).

Not Medically Necessary / Experimental Procedures and Devices

Other Non-Surgical Procedures - Not Medically Necessary

The following are unproven and not medically necessary due to insufficient evidence of efficacy:

Devices for treating Positional OSA

Nasal dilator devices for treating OSA

Intranasal expiratory resistance valve (e.g., Bongo Rx)

Removable Oral Appliances for treating Central Sleep Apnea

Prefabricated Oral Appliance/device

Non-surgical electrical muscular training

Mandibular vertical repositioning devices (e.g., Slow Wave)

Morning repositioning devices

Epigenetic appliances (e.g., Homeoblock™, DNA® Daytime/Nighttime appliance)

Advanced Lightwire Functional (ALF) appliances

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.

Provider Actions / Administrative Requirements

Documentation Required

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

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.

Prior Authorization

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.

Denial Risk

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.

Documentation Required

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.

Billing Rule

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.

E0490 - Verify current Prior Authorization and Notification List for UnitedHealthcare Community Plan of Indiana

Documentation Required

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.

Documentation Required

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 Evidence Summary

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:

Devices/Procedures with Insufficient/No Quality Evidence to Support Efficacy for OSA: Mandibular vertical repositioning devices (e.g., slow wave) — no quality evidence supporting efficacy and safety for OSA.||Morning repositioning devices — no published studies identified; effect on health outcomes unknown.||Epigenetic appliances — no quality evidence to support efficacy for OSA.||Advanced Lightwire Functional (ALF) appliances — no quality evidence to support efficacy for OSA.||Uvulectomy as a standalone procedure — insufficient evidence to conclude effectiveness for OSA.||Palatal implants (Pillar, Elevo) — insufficient evidence to conclude effectiveness for OSA; mixed small trials and RCTs with limited or inconsistent benefits.

Procedures With Promising But Insufficient Evidence / Need More Research: Implantable neurostimulation devices (remedē transvenous phrenic nerve stimulation) for CSA — very-low- to low-quality evidence; shows reductions in AHI/CAI but clinical impact (eg, mortality, long-term morbidity) uncertain; additional RCTs and long-term data needed.||Laser-assisted uvulopalatoplasty (LAUP) — some small studies show AHI improvement but systematic reviews indicate high complication rates and potential to worsen OSA; insufficient evidence for effectiveness.||Lingual suspension/tongue fixation (various techniques) — case series and small studies show variable success; evidence limited by small size, lack of controls; insufficient to establish safety/efficacy.||Hyoid myotomy/hyoid suspension — some case series and small nonrandomized studies report AHI improvements, but evidence insufficient; additional high-quality studies needed.

Guideline Recommendations Included: AAO-HNS: face-to-face evaluation by qualified physician recommended; oral appliance recommended as first-line for snoring and for mild-to-moderate OSA.||AASM: CPAP/APAP recommended for OSA; custom titratable oral appliances preferred over non-custom when prescribed; follow-up sleep testing recommended after oral appliance therapy; collaboration between sleep physicians and qualified dentists recommended.||AADSM: patient must be referred to a medical provider for diagnosis; OAT may be recommended when CPAP intolerant; QD should collaborate with medical providers.||AAOMS: custom-made oral appliances effective for mild-to-moderate OSA; may be indicated in severe OSA who failed CPAP; should be fitted by qualified dental personnel.||ACP: CPAP recommended as initial therapy for patients diagnosed with OSA; encourage weight loss in overweight/obese OSA patients.||ERS: suggests CPAP vs custom MAD based on very low-quality evidence; notes positional therapy or CPAP for position-dependent OSA; myofunctional therapy suggested only in specific cases.

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.

Revision History

2025-11-01addedLatest

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)

2025-11-01revisedLatest

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)

2025-11-01addedLatest

Added definition of 'Respiratory Disturbance Index (RDI)'. (non-material)

2025-11-01addedLatest

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)

2025-11-01updatedLatest

Updated FDA and References sections to reflect the most current information; archived previous policy version CS116IN.16. (non-material)