Obstructive and Central Sleep Apnea Treatment (for Idaho Only)
State-specific UnitedHealthcare (Idaho) medical policy defining medical necessity criteria for non-surgical and surgical treatments for obstructive and central sleep apnea, listing proven vs unproven therapies, device coverage positions, applicable codes, documentation requirements, and definitions. This is Part 1 of 5 of the full policy.
Revised language pertaining to medical necessity clinical coverage criteria for oral appliances; providers instructed to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.30: Oral Appliances.
Revised list of unproven and not medically necessary indications by removing several oral appliance/device types from the list (removable oral appliances for CSA, prefabricated devices, Slow Wave, morning repositioning devices, epigenetic appliances, ALF appliances).
Added notation that polysomnography should be repeated if clinically significant weight loss or gain, changes in cardiovascular disease, or persistent or recurrent symptoms occur since the last study.
Revised coverage criteria for UPPP, MO, and MMA to require moderate to severe OSA defined as AHI ≥ 15 or RDI ≥ 15 determined by attended polysomnography.
Revised Implantable HNS adult criteria to require total AHI < 25% for central + mixed apneas as evaluated by attended polysomnography and require absence of complete concentric collapse confirmed by drug-induced sleep endoscopy.
Removed prior language indicating implantable HNS is proven and medically necessary in adolescents aged 10-18 years with Down syndrome when specified criteria were met.
Added CPT/HCPCS codes 0964T, 0965T, 0966T, and E0490 to Applicable Codes.
Updated Description of Services, Clinical Evidence, FDA, and References sections and archived previous policy version CS116ID.B.
Updated definition of Body Mass Index (BMI) in the Definitions section.
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