Moda Health Medical Necessity Criteria Origination Date: 7/02

Subject: Obstructive Sleep Apnea Surgical Treatment Page 1 of 5 Revision Date(s): 4/03, 6/04, 6/05, 6/06, 6/07, 7/08, 3/09, 12/09, 3/11, 5/11, 3/12, 01/13, 01/14, 01/15

Developed By: Medical Criteria Committee

Approved:

Mary Engrav, MD

Date:

01/28/2015

Description: Airway obstruction during sleep is a commonly recognized problem. Obstructive sleep apnea (OSA) is the most common breathing related sleep disorder. OSA is characterized by repetitive episodes of airway obstruction due to the collapse and obstruction of the upper airway during sleep. In patients with OSA, the normal pharyngeal narrowing is accentuated by anatomic factors, such as a short neck, elongated palate and uvula, large tonsils and redundant lateral pharyngeal wall mucosa. The hallmark symptom of OSA is excessive snoring. The snoring abruptly ceases during the apneic episodes and during a brief awakening period and then resumes when the patient falls asleep again. When noninvasive treatment such as continuous positive airway pressure (CPAP) fails to adequately treat OSA or is not tolerated by the patient, surgical intervention may be warranted. The most common form of surgical management in treating OSA is an uvulopalatopharyngoplasty (UPPP). UPPP involves resection of the mucosa and submucosa of the soft palate, tonsillar fossa, and the lateral aspect of the uvula. The UPPP enlarges the oropharynx but cannot correct obstructions in the hypopharynx. Other minimally invasive surgical procedures have been investigated as treatments for OSA; however, inadequate data exists to establish long-term effectiveness. Criteria: CWQI: HCS-0054 Surgical Treatment: 1. Moda Health will cover Uvulopalatopharyngoplasty (UPPP) to plan limitations when All of the following criteria are met: a. Moderate to severe obstructive sleep apnea diagnosed by a sleep study within the past two years prior to any proposed surgery and reviewed by a Board Certified Sleep Medicine Physician b. Narrowing or collapse of retropalatal region c. Patient must have an Apnea Hypopnea Index (AHI) of 1 or more of the following: i. Moderate AHI: 15-30 ii. Severe AHI: >30 iii. Mild AHI between 5 and 14 if 1 or more of the following criteria are met:

Moda Health Medical Necessity Criteria

Subject: Obstructive Sleep Apnea Surgical Treatment Page 2 of 5 Revision Date(s): 4/03, 6/04, 6/05, 6/06, 6/07, 7/08, 3/09, 12/09, 3/11, 5/11, 3/12, 01/13, 01/14, 01/15

Origination Date: 7/02

Developed By: Medical Criteria Committee 1. 2. 3. 4. 5. 6. 7.

Excessive daytime sleepiness that interferes with activities of daily living (ADL) (e.g. causes safety issues) Insomnia Impaired cognition Mood disorders Documented hypertension Ischemic heart disease History of stroke

d. Patient must have failed medical therapy with well documented follow-up involvement by a qualified sleep specialistwhich includes All of the following: i. CPAP therapy including inability to tolerate CPAP or BiPAP as appropriate ii. Maximal treatment of underlying disease iii. Other appropriate non-invasive therapy iv. Oral appliance e. Excessive daytime sleepiness that is not explained by other etiologic factors f.

Uvulectomy will be covered to plan limitations when all of the above criteria for UPPP are met.

g. Radiofrequency volumetric tissue ablation of the soft palate, uvula, tongue base, or of the nasal passages, turbinates and/or soft palate (Somnoplasty™ or Coblation) is considered investigational and is NOT covered by Moda Health. Not Covered: The following procedures are not covered by Moda Health: 1. The Repose System, a minimally invasive technique involving tongue base suspension, is considered investigational. 2. Injection snoreplasty: injection of a sclerosing agent into the soft palate is considered investigational. 3. Palatal stiffening procedures, including but not limited to, cautery-assisted palatal stiffening operation (CAPSO), and the implantation of palatal implants (Pillar™ Palatal Implant System) are considered investigational. 4. Somnoplasty and Coblation 5. Transpalatal Advancement Pharyngoplasty 6. Nasal Surgery 7. Any surgical procedure for simple snoring in the absence of obstructive sleep apnea is considered not medically necessary. 8. Laser –assisted uvulopalatopharyngoplasty (LAUP)

Moda Health Medical Necessity Criteria Origination Date: 7/02

Subject: Obstructive Sleep Apnea Surgical Treatment Page 3 of 5 Revision Date(s): 4/03, 6/04, 6/05, 6/06, 6/07, 7/08, 3/09, 12/09, 3/11, 5/11, 3/12, 01/13, 01/14, 01/15

Developed By: Medical Criteria Committee Information to be Submitted with Pre-Authorization Request: 1. Sleep study interpretation 2. CPAP trial results 3. Medical records from treating physician documenting the requirements Applicable CPT/HCPC Codes: Note: list may not be all inclusive CPT/HCPC Code 42140 42145

Description Uvulectomy, excision of uvula Palatopharyngoplasty (e.g. uvulopalatopharyngoplasty, uvulopharyngoplasty)

CPT/HCPC Codes NOT Covered: CPT/HCPC Code 41512 41530 C9727 S2080 42160 42890 30801

30802 42950

Description Tongue base suspension, permanent suture technique Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session Insertion of implants into the soft palate; minimum of 3 implants Laser-assisted uvulopalatoplasty (LAUP) Destruction of lesion, palate or uvula (thermal, cryo, or chemical) Limited pharyngectomy Ablation, soft tissue of inferior turbinates, unilateral or bilateral any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial Intramural Pharyngoplasty (plastic or reconstructive operation on pharynx) (for Palatal stiffening procedure and Transpalatal advancement pharyngoplasty)

Applicable ICD-9 Codes: ICD-9 Codes 327.20 327.23 327.29 780.51 780.53

Diagnosis Organic sleep apnea, unspecified Obstructive sleep apnea (adult) (pediatric) Other organic sleep apnea Insomnia with sleep apnea, unspecified Hypersomnia with sleep apnea, unspecified

Moda Health Medical Necessity Criteria Origination Date: 7/02

Subject: Obstructive Sleep Apnea Surgical Treatment Page 4 of 5 Revision Date(s): 4/03, 6/04, 6/05, 6/06, 6/07, 7/08, 3/09, 12/09, 3/11, 5/11, 3/12, 01/13, 01/14, 01/15

Developed By: Medical Criteria Committee 780.57

Unspecified sleep apnea

Applicable ICD-10 Codes: ICD-10 Codes G47.30 G47.33 G47.39 G47.9

Review Date 01/2013

01/2014

01/2015 07/2015

Diagnosis Sleep apnea, unspecified Obstructive sleep apnea (adult) (pediatric) Other sleep apnea Sleep disorder, unspecified

Revisions Annual Review: Added table with review date, revisions, and effective date. Added Dr. Engrav’s signature instead of Dr. Mills Annual Review: Changed 1,e, iv – from mandibular repositioning or tongue-retaining appliance to oral appliance Annual Review: No change Added ICD-9 and ICD-10 codes

Effective Date 01/23/2013

01/22/2014

01/28/2015

References:  American Academy of Otolaryngology (AAO) Website. Accessed May 27, 2004.on March 24, 2012 at: www.entnet.org  American Academy of Otolaryngology Head and Neck Surgery. 2000 Clinical Indicators Compendium.  Epworth Sleepiness Scale. University of Maryland medical Center. (2011). Accessed on February 25, 2011.  Friedman M, Ibrahim H, Joseph NJ. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope. 2004 March; 114(3):4549.  Han S, Kern RC. Laser-assisted uvulopalatoplasty in the management of snoring and obstructive sleep apnea syndrome. Miverva Med. 2004 Aug; 95(4):337-45.  Hensley N, Ray C. Sleep apnoea. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2008.  Li KK. Surgical management of obstructive sleep apnea. Clinics in Chest Medicine. 2003: 24(2).  Loube DI. Technologic advances in the treatment of obstructive sleep apnea

Moda Health Medical Necessity Criteria Origination Date: 7/02

Subject: Obstructive Sleep Apnea Surgical Treatment Page 5 of 5 Revision Date(s): 4/03, 6/04, 6/05, 6/06, 6/07, 7/08, 3/09, 12/09, 3/11, 5/11, 3/12, 01/13, 01/14, 01/15

Developed By: Medical Criteria Committee syndrome. Chest 1999; 116(5): 1426-33.  Masood A, Phillips B. Radiofrequency ablation for sleep-disordered breathing. Curr Opin Pulm Med. 2001:7(6): 404-406.  Medicare Guidelines for Treatment of Obstructive Sleep Apnea. Medicare Part B Policy 2002.13.  Sundaram S, Bridgman SA, Lim J, Lasseron TJ. Surgery for obstructive sleep apnea. Cochrane Database Syst Rev. 2005 Oct; (4):CD001004.  Physician Advisors