ModifiedUnitedHealthcarePolicy CS11GIN.16

Obstructive and Central Sleep Apnea Treatment (for Indiana Only)

Medical policy governing non‑surgical and surgical treatments for obstructive and central sleep apnea for UnitedHealthcare members in Indiana, including device and procedure coverage stance and referenced coding and clinical criteria.

Policy Summary

PayerUnitedHealthcare

PolicyObstructive and Central Sleep Apnea Treatment (for Indiana Only)

Policy CodePolicy CS11GIN.16

Change TypeRevised device listadded definitionscode management clarifications (material changes)

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain InterQual documentation and prior authorization when seeking coverage for removable oral appliances or implantable devices; follow state prior authorization lists for Indiana.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary devices; replaced several device naming conventions and added definitions (Sleep Medicine Training, BMI).

Added notation that CPT code 21685 is not managed for medical necessity review for the state of Indiana at this time and removed notation about HCPCS L8679 for Indiana.

Added definition of 'Sleep Medicine Training' and updated definition of Body Mass Index (BMI).

04/01/2025policy revision date

InterQualInterQual referenced

CS116IN.15archived prior version

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

~7FDA devices referenced

51% vs 11%TPNS RCT responder

Coverage Criteria and Evidence-Based Stances

Transoral Robotic Surgery (TORS) for base of tongue reduction

Transoral Robotic Surgery (TORS) for base of tongue reduction — Considered promising in selected patients but evidence is limited. Coverage stance and criteria are summarized below.

ALL of the following

TORS for base of tongue (BOT) reduction is considered when used as part of a comprehensive, guideline-concordant surgical plan for OSA (eg, multilevel surgery) and when conservative therapies have failed or are not tolerated.
See guideline references (AASM, AAO-HNS) for sequencing of surgery after PAP and/or oral appliance failure.
Documented diagnosis of obstructive sleep apnea confirmed by polysomnography (PSG) or equivalent sleep testing with preoperative apnea-hypopnea index (AHI) consistent with the clinical rationale for surgery.
Include baseline AHI and symptom severity (eg, ESS).
Prior appropriate medical therapy trial and failure or intolerance of first-line noninvasive therapy (eg, adequate trial of CPAP and/or oral appliance therapy when indicated), with documentation of adherence attempts and reasons for failure or intolerance.
If PAP not feasible, document contraindication or intolerance.
Patient selection based on anatomic assessment demonstrating tongue base or hypopharyngeal obstruction as a primary or major contributor to airway collapse (eg, drug-induced sleep endoscopy, fiberoptic examination), and multidisciplinary evaluation confirming TORS is appropriate for the individual.
Document findings from DISE or equivalent assessment and multidisciplinary team recommendation.
Surgery performed by a qualified surgeon with appropriate training and experience in TORS procedures and after discussion of risks, benefits, and alternatives with the patient; informed consent should document the novel/limited evidence status of TORS for OSA.
Surgeon credentials and operative plan should be in the record.
Availability of follow-up plan including postoperative sleep testing (eg, PSG or home sleep study) to assess efficacy and documentation of ongoing clinical monitoring for complications and symptomatic response.
Postoperative sleep testing timing and measures should be specified in the record.
Coverage is conditional and may be considered on a case-by-case basis; TORS performed solely as an isolated procedure without appropriate patient selection, or in the absence of documentation meeting the above criteria, is not routinely covered due to limited high-quality evidence and heterogeneous outcomes in published studies.
Refer to policy for unproven/not medically necessary procedures when criteria are not met.

Applicable Procedure and Device Codes

Procedural CPT/other codesCPT

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)], including vessel catheterization, all imaging guidance, and generator initial analysis with diagnostic mode activation, when performed
33277	Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure)
33278	Removal of phrenic nerve stimulator; including vessel catheterization, all imaging guidance, and interrogation and programming; when performed; system, including pulse generator and lead(s)
33279	Removal of phrenic nerve stimulator; including vessel catheterization, all imaging guidance, and interrogation and programming; when performed; transvenous stimulation or sensing lead(s) only
33280	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming; when performed; pulse generator only
33281	Repositioning of phrenic nerve stimulator transvenous lead(s)

1–10 of 25

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HCPCS / DME / Implantable device codesHCPCS

A7049	Expiratory positive airway pressure intranasal resistance valve
E0485	Oral devicelappliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment
E0486	Oral devicelappliance used to reduce upper airway collapsibility , adjustable or nonadjustable, custom fabricated; includes fitting and adjustment
E0492	Power source and control electronics unit for oral devicelappliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application
E0493	Oral devicelappliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit; controlled by phone application, 90- supply day
E0530	Electronic positional obstructive sleep apnea treatment; with sensor; includes all components and accessories, any type
E1399	Durable medical equipment; miscellaneous
K1027	Oral devicelappliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes and adjustment fitting
L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each

1–10 of 13

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FDA device clearances/approvals referencedmixed

K030108	ArthroCare ENT Coblator Surgery System 510(k)
K982717	Somnoplasty System 510(k)
K040417	Pillar Palatal Implant System 510(k)
P130008	Inspire Upper Airway Stimulation (PMA)
DEN200018	eXciteOSA de novo classification (device code QNO)
K180619	Bongo intranasal appliance 510(k)
K191320	Slow Wave DS8 510(k)

Applicable Codes with state management notesCPT | HCPCS

21685	CPT 21685 (not managed for medical necessity review for Indiana at this time — notation in policy history)
L8679	HCPCS L8679 (notation removed regarding Indiana management)

OSA severity by AHI/RDI

Mild OSAAHI or RDI > 5 and < 15 events/hour

Moderate OSAAHI or RDI > 15 and < 30 events/hour

Severe OSAAHI or RDI >= 30 events/hour

Inspire UAS AHI and BMI limits (FDA indication)

AHI eligibility (original FDA PMA)AHI >= 20 and < 65 (original PMA indication)

AHI eligibility (2023 expanded)Lower AHI limit expanded to < 15 for select patients; baseline upper AHI limit expanded from 65 to 100

Prior Authorization, Documentation, and Billing Rules

Prior Authorization

Prior Authorization Required / Managed Codes

Prior authorization is required for many implantable devices and certain DME/HCPCS items; inclusion of a code in this policy is for reference only and does not guarantee coverage. Refer to the current UnitedHealthcare Prior Authorization and Notification lists and to state/contract-specific requirements (federal, state, or contractual benefit terms govern in case of conflict). InterQual criteria are used to determine medical necessity for removable oral appliances and for implantable hypoglossal nerve stimulation where indicated.

Check the Prior Authorization and Notification List for the most up-to-date managed codes and state-specific exceptions (e.g., CPT 21685 not managed for medical necessity review for Indiana at the time of this policy).
Codes listed with an asterisk in the Applicable Codes section are not managed for medical necessity review for Indiana at policy effective date — always verify current prior authorization lists.

Prior Authorization

Prior Authorization Consideration for EPAP Devices

Intranasal EPAP devices (e.g., Provent) have mixed evidence: some randomized trials show short-term reductions in AHI or symptom improvement while others show inferiority to CPAP. Given variable efficacy and limited long-term comparative data, prior authorization is recommended and documentation of prior therapy, indication, and objective sleep study results should be provided.

Clinical Background and Scope

Obstructive Sleep Apnea (OSA) is characterized by episodic reduction or cessation of airflow due to upper airway collapse during sleep, resulting in symptoms such as daytime sleepiness and increased cardiovascular and metabolic risk. Central Sleep Apnea (CSA) involves loss of ventilatory drive and is often associated with heart failure; treatments for CSA have limited acceptance because of sparse evidence for effectiveness and safety. Diagnosis is established using attended polysomnography (PSG) or home sleep apnea testing (HSAT) as clinically appropriate.

Key Terms and Device Definitions

AHI — Apnea Hypopnea Index

DefinitionApnea Hypopnea Index (AHI): number of apneas plus hypopneas during the entire sleeping period, times 60, divided by total sleep time in minutes; unit events per hour (AASM Scoring Manual, 2023).

UseReported as events per hour to categorize OSA severity

Source guidanceDefinition adapted from AASM Scoring Manual as cited in the policy

BMI — Body Mass Index

DefinitionBody Mass Index (BMI): weight in kilograms divided by the square of height in meters.

Normal weightBMI 18.5 to 24.9 kg/m2

Policy Revision History

2025-04-01policy_revisionLatest

Revised coverage rationale for non-surgical treatments including an updated list of devices classified as unproven/not medically necessary; added definition of 'Sleep Medicine Training' and updated the definition of Body Mass Index (BMI); noted state-specific code management changes for Indiana (CPT 21685 not managed; HCPCS L8679 notation removed); updated Description of Services, Clinical Evidence, FDA, and References; archived prior version CS116IN.15.

Policy Summary

PayerUnitedHealthcare

PolicyObstructive and Central Sleep Apnea Treatment (for Indiana Only)

Policy CodePolicy CS11GIN.16

Change TypeRevised device listadded definitionscode management clarifications (material changes)

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain InterQual documentation and prior authorization when seeking coverage for removable oral appliances or implantable devices; follow state prior authorization lists for Indiana.

SourceLink

On This Page

BMI upper limitOriginal BMI upper limit 32; expanded to 40 in 2023 FDA indication expansion

Epworth Sleepiness Scale reference

Assessment tool referencedEpworth Sleepiness Scale (ESS) is cited as a common subjective sleepiness measure used in trials and required supporting documentation

Role in documentationESS commonly included pre- and post-treatment in device and surgical studies to document symptom change

ThresholdsNo specific numeric ESS threshold is provided in the cited policy chunks

EPAP devices (HCPCS A7049/E0485 as applicable) require prior authorization and supporting clinical documentation.
If EPAP is requested as an alternative to PAP, include documentation of CPAP intolerance, trial and outcomes, and recent polysomnography results.

Prior Authorization

Prior Authorization for TPNS (Implantable Phrenic Nerve Stimulation)

Transvenous phrenic nerve stimulation (TPNS; e.g., remede System) is supported by randomized trial data showing reductions in AHI for selected patients with central sleep apnea, but the overall evidence base is limited and additional comparative and long-term outcomes data are needed. Prior authorization is required for implantable phrenic nerve stimulation devices.

Provide device-specific eligibility documentation consistent with FDA indication for remede and any device labeling changes.
Include prior authorization for HCPCS L8679/L8680/L8686 as applicable and verify current managed-code lists.

Prior Authorization

Prior Authorization Recommended for Procedures with Limited Evidence

Procedures and devices with limited, insufficient, or low-quality evidence (eg, many surgical techniques, positional devices, certain novel oral appliances) commonly require prior authorization and may be denied if adequate supporting documentation is not provided. Prior authorization allows case review for medical necessity given the heterogeneity and limited long-term data for many interventions.

Examples that typically require prior authorization and strong supporting clinical rationale: LAUP, DOME, hyoid myotomy, radiofrequency ablation, implantable neurostimulators for novel indications, and custom/novel oral appliances.
Lack of comparative trials, long-term outcomes, or demonstration of prior standard therapy trials increases the chance of denial.

Documentation Required

Prior Authorization: Implantable Device Eligibility

Implantable systems (hypoglossal nerve stimulators, TPNS, implantable pulse generators/electrodes) generally require prior authorization and device-specific eligibility documentation. Documentation should demonstrate that the patient meets FDA-labeled indications (or other applicable regulatory criteria) and that guideline-recommended conservative therapies were attempted or were not tolerated.

Include device model, FDA indication, baseline AHI and other polysomnography metrics, BMI, prior PAP trial documentation, and evidence of failure/intolerance to PAP when applicable.
Confirm any expanded or pediatric indications per most recent FDA updates prior to authorization decision.

Denial Risk

Denial Triggers for Unproven Devices

Use of devices judged unproven and not medically necessary (for example positional QSA devices when not supported, intranasal expiratory resistance valves in some indications, prefabricated oral appliances, removable oral appliances for CSA, non-surgical electrical muscular training, ALF appliances, and other listed devices) may trigger claim denials.

Prefabricated oral appliances and removable oral appliances for central sleep apnea are considered unproven and may be denied.
Advanced Lightwire Functional (ALF) appliances lack quality evidence and may be denied as not medically necessary.

Denial Risk

Oral Appliances for CSA Unsupported

There is no relevant evidence to support removable oral appliances for treatment of central sleep apnea (CSA); requests for such devices should be denied in absence of compelling, high-quality supporting evidence.

Documented CSA diagnosis alone is not sufficient to approve removable oral appliances — current evidence does not support effectiveness for CSA.

Denial Risk

ALF Evidence Insufficiency (Denial Risk)

Advanced Lightwire Functional (ALF) appliances are listed among devices without quality evidence supporting efficacy for OSA. Because evidence is insufficient, claims for ALF appliances may be denied.

Provide high-quality evidence if requesting coverage for ALF; absent that, expect denial as not medically necessary.

Note

Insufficient Comparative Evidence Across Many Procedures

Across many surgical and device interventions for sleep-disordered breathing, there is insufficient high-quality comparative evidence and limited long-term outcomes. This uncertainty supports a conservative, stepwise approach to therapy and justifies prior authorization and careful documentation for higher-risk or resource-intensive procedures.

When comparative effectiveness evidence is lacking, prior authorization reviewers will expect documentation of prior standard therapies and rationale for the selected intervention.
Lack of randomized controlled trials or long-term follow-up increases the likelihood of additional information requests or denial.

Billing Rule

State- and Contract-Specific Requirements May Trigger Denial

Coverage decisions may vary by federal or state law and by contract; state- and contract-specific requirements may lead to differing coverage outcomes or denials. Always verify the member’s governing benefit plan and applicable state prior authorization rules before proceeding.

Example: CPT 21685 is not managed for medical necessity review for the state of Indiana at the effective date of this policy — always check current Prior Authorization and Notification lists.
In the event of conflict between this policy and federal/state/contractual requirements, the federal/state/contractual requirements govern.

Billing Rule

Coding and Documentation Notes

Coding and documentation notes: the Applicable Codes list is for reference; HCPCS E0486 applies to custom fabricated oral appliances; certain codes (asterisked) were noted as not managed for Indiana at policy effective date. Dental services (D-codes) are generally excluded from the medical plan. Inclusion of a code does not guarantee coverage or reimbursement.

Verify current code management status and prior authorization requirements before submitting claims.
Provide appropriate CPT/HCPCS codes, device model numbers, and linkage to clinical documentation when requesting authorization.

Documentation Required

Specialist Evaluation Required

A face-to-face evaluation by a qualified physician trained in Otolaryngology–Head and Neck Surgery or Sleep Medicine is recommended before consideration of many surgical or device therapies for OSA. Specialist evaluation helps ensure appropriate selection and sequencing of therapies.

AAO-HNS recommends evaluation by a physician with appropriate certification (eg, American Board of Sleep Medicine or American Board of Otolaryngology).
Referral to a qualified dentist (QD) should follow a confirmed medical diagnosis of OSA when oral appliance therapy is considered.

Documentation Required

Medical Diagnosis and Interdisciplinary Collaboration

Documentation should demonstrate a confirmed medical diagnosis of OSA or CSA, prior evaluation and management by appropriate medical providers, and interdisciplinary collaboration between sleep physicians and surgeons or dentists when applicable.

Include diagnostic sleep study reports (PSG or HSAT), Epworth Sleepiness Scale (ESS), BMI, comorbidity assessment, and records of prior PAP trials and outcomes.
Evidence of collaboration between sleep medicine specialists and dentists or surgeons is expected for device- or procedure-based therapies.

Documentation Required

TPNS Documentation

For TPNS (remede) prior authorization and clinical review, include comprehensive device-specific documentation: baseline and follow-up polysomnography metrics, diagnosis of CSA, prior trials of guideline-recommended therapies, device model and FDA indication, and detailed reports of therapy tolerance and adverse events.

Required documentation typically includes baseline AHI/CAI, ESS scores, prior PAP trial documentation or contraindications, and device-specific eligibility per labeling.
Report procedural and device-related adverse events and long-term follow-up data if available to support continued coverage decisions.

Documentation Required

Required Supporting Clinical Documentation

Required supporting clinical documentation for prior authorization requests commonly includes pre- and post-intervention polysomnography (AHI), Epworth Sleepiness Scale (ESS), objective documentation of CPAP trial and intolerance or failure, BMI, and specialist consultation notes. Lack of these elements may lead to denial or requests for additional information.

Pre- and postoperative sleep study data, ESS, and documentation of CPAP intolerance/failure are routinely requested for surgical/device authorizations.
Include dates, titration data, adherence reports, and any attempts to optimize PAP prior to declaring intolerance.

Documentation Required

Documentation and Governing Rules

When applying this policy, always reference and document the member’s governing federal, state, or contractual benefit requirements as those terms may differ from this standard policy and will govern in case of conflict. UnitedHealthcare may use third-party tools (eg, InterQual) to assist in administration; this policy is informational and does not substitute for clinical judgment.

If a conflict exists between this policy and federal/state/contractual requirements, the latter govern.
Use InterQual criteria where indicated to support medical necessity determinations for removable oral appliances and implantable hypoglossal nerve stimulation.

Step Therapy

Stepwise Management Expectation

The evidence summaries and guideline recommendations support a stepwise management expectation: CPAP (PAP) is generally the first-line therapy for most patients with moderate to severe OSA; surgical or device-based therapies are generally considered when PAP is not tolerated or has failed and after appropriate specialist evaluation.

Prior authorization reviewers will look for documented trials of PAP and attempts to optimize adherence before approving surgical or implantable device therapy.
Policies reflect guideline preference for CPAP as initial therapy and consider oral appliance therapy for CPAP-intolerant patients.

Step Therapy

Prioritize PAP Before Surgical/Device Therapy

Guideline-concordant care prioritizes positive airway pressure (PAP) therapy (eg, CPAP/APAP) before considering surgical or implantable device therapies for moderate to severe OSA. Documented PAP failure or intolerance and shared decision-making should be included in authorization requests for alternative therapies.

CPAP is consistently more effective at reducing AHI than positional therapies or EPAP in comparative studies and should be documented as tried when clinically appropriate.
When PAP cannot be tolerated, include objective adherence and optimization efforts in the authorization documentation to support consideration of alternative treatments.

Overweight and obesity classes

Overweight 25–29.9 kg/m2; Obesity Class I 30–34.9 kg/m2; Class II 35–39.9 kg/m2; Class III >= 40 kg/m2

HSAT — Home Sleep Apnea Testing

DefinitionHome Sleep Apnea Testing (HSAT): unattended diagnostic studies to assess for OSA without determination of sleep stage; also referred to as out-of-center sleep testing or portable monitoring.

Typical componentsHSAT usually records airflow, respiratory effort (e.g., inductance plethysmography), and oximetry

RoleUsed to diagnose OSA in appropriate patients outside the sleep laboratory setting

Oral Appliance — Definition and types

DefinitionOral appliance: device inserted into the mouth for treatment of snoring or OSA; devices may be prefabricated (ready-made) or custom made.

TypesPrefabricated (ready-made) appliances versus custom-fabricated mandibular repositioning devices; evidence favors custom devices for efficacy and tolerance

Clinical noteCustom-made devices typically require dental fitting and follow-up; prefabricated devices lack quality evidence for OSA efficacy

Polysomnogram — Attended lab sleep study

DefinitionPolysomnogram (Attended): laboratory-based multi-channel sleep study recording physiological parameters including brain activity, eye movements, body movements, breathing and heart rate.

UseGold-standard diagnostic test for OSA severity determination and AHI measurement

SettingPerformed in an attended sleep laboratory with trained technologists

EPAP — Expiratory positive airway pressure

DefinitionEPAP (expiratory positive airway pressure): a nasal device that increases expiratory resistance (example: Provent) intended to reduce OSA severity.

Evidence summaryRandomized trials show short-term reductions in AHI versus sham in some patients but EPAP is inferior to CPAP for moderate-to-severe OSA; adherence and long-term responder data are limited.

ExamplesProvent (intranasal EPAP) and similar expiratory resistance valve devices

Positional therapy / Sleep Position Trainer

DefinitionPositional therapy / Sleep Position Trainer (SPT): devices (e.g., vibratory trainers or chest-worn NightBalance) intended to discourage supine sleep in patients with positional OSA.

Intended populationPatients with positional OSA (lower AHI in nonsupine than supine position; trials enrolled those with AHI 5-30 and 10–90% supine sleep).

Device examplesNightBalance chest-worn trainer and similar vibratory position trainers

eXciteOSA — Intraoral awake-use electrical stimulation device

DefinitioneXciteOSA: an intraoral, awake-use electrical stimulation device targeting tongue musculature to reduce snoring and mild OSA; used for daily awake sessions per manufacturer guidance.

EvidenceEvidence limited to single-arm studies and low-quality trials; assessments (Hayes, ECRI) conclude evidence is inconclusive and further RCTs with long-term outcomes are needed.

Use caseProposed for mild OSA or primary snoring; not established as comparative alternative to CPAP or oral appliance therapy

ALF appliance — definition and evidence note

DefinitionALF appliance: Advanced Lightwire Functional appliance, a cranial osteopathy-based orthodontic system using light flexible wire intended to widen or reposition jaws.

Evidence notePolicy states there is no quality evidence to support efficacy of ALF appliances for OSA; use may trigger denial as unsupported.

Clinical implicationNot recommended as standard OSA therapy based on current evidence

TPNS — Transvenous phrenic nerve stimulation (remede System)

DefinitionTPNS (transvenous phrenic nerve stimulation; remede System): an implantable system delivering unilateral phrenic nerve stimulation to treat central sleep apnea (CSA).

EvidenceRandomized trial showed greater proportion achieving >=50% AHI reduction at 6 months with stimulation (51%) vs control (11%), with overall limited long-term data.

Regulatory contextremede System received FDA approval for treatment of moderate-to-severe CSA in adults (Pivotal trial cited).

TOTS / Lingual suspension — definition and examples

DefinitionTOTS / Lingual suspension: surgical techniques that mechanically suspend or stabilize the tongue base to reduce obstruction (examples include suture-based suspension, Repose, Advance systems).

ExamplesSuture-based tongue suspension techniques and transoral approaches described in case series (TOTS).

Evidence noteAvailable studies are small, often combined with other procedures, and lack long-term comparative data; consider investigational or conditional coverage.

RFTVR / RFA — Radiofrequency tissue volume reduction

DefinitionRFTVR / RFA: use of low-intensity radiofrequency energy to reduce tissue volume of the uvula, soft palate, and/or tongue to reduce airway obstruction (trade names: Somnoplasty, Coblation).

RoleMay provide short-term reductions in respiratory disturbance indices and symptom scores; long-term safety and efficacy are inadequately established.

Clinical noteOften performed in conjunction with other therapies; randomized trials and larger studies needed for definitive conclusions.

TORS — Transoral Robotic Surgery

DefinitionTORS (Transoral Robotic Surgery): robotic-assisted transoral approach to resect or reduce base-of-tongue tissue to treat OSA, frequently as part of multilevel surgical strategies.

Typical roleUsed for base-of-tongue reduction within multilevel surgery for selected patients with tongue-base obstruction; reported success rates vary across case series and meta-analyses.

Evidence noteMeta-analyses report pooled surgical success rates (e.g., ~68–69%) but studies are largely retrospective with variable complication rates (average ~22% in some series).

TORS (additional) — BOT reduction definition and context

DefinitionRobotic-assisted base-of-tongue (BOT) reduction: use of robotic tools to perform precise resection/reduction of tongue-base tissue, typically as part of multilevel OSA surgery.

ContextReported in systematic reviews and meta-analyses with improvements in AHI and ESS, but evidence limited by retrospective designs and lack of comparison groups.

RisksSome series report notable complication rates and selection bias; patient selection optimization is important.

DOME — Distraction Osteogenesis for Maxillary Expansion

DefinitionDOME (Distraction Osteogenesis for Maxillary Expansion): surgical expansion of the maxilla using distractor devices (bone- and tooth-borne hybrid expanders) intended to enlarge the upper airway.

Intended effectAims to widen the maxilla to improve nasal airflow and reduce AHI in select CPAP-intolerant OSA patients.

Evidence noteInsufficient quality evidence (no randomized controlled trials); published literature consists mainly of small retrospective case series with limited long-term outcomes.

Upper Airway Stimulation (UAS/Inspire) — definition and device context

DefinitionUpper Airway Stimulation (UAS/Inspire): an implantable hypoglossal nerve stimulation system (Inspire) indicated for selected adults with OSA who fail or cannot tolerate PAP therapy and who meet device-specific anatomical and AHI/BMI criteria.

Device contextInspire received FDA PMA (P130008) with indications based on AHI ranges and absence of complete concentric collapse; FDA expanded indications in 2023 to adjust AHI and BMI limits.

Clinical requirementPatient selection should follow FDA labeling and guideline-directed sequencing, including prior PAP failure/intolerance and assessment for concentric collapse.

Sleep Medicine Training — added definition (policy revision)

Definition added in revisionSleep Medicine Training: a definition was added in the policy revision (exact text not present in the cited chunks).

Policy noteThe policy history records addition of a Sleep Medicine Training definition on 04/01/2025; refer to full policy for exact wording.

UseDefinition intended to clarify required specialist training for certain procedures or evaluations referenced in the policy.

Body Mass Index (BMI) — updated definition (policy revision)

Updated definition noteBody Mass Index (BMI): policy revision updated the BMI definition on 04/01/2025; exact updated text is not present in the cited chunks.

ReferencePolicy history indicates BMI definition updated; the main BMI calculation remains weight (kg) divided by height (m) squared as cited elsewhere in the document.

ImplicationSee full policy text for the precise revised BMI wording and any related classification changes used for coverage determinations.