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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 
 
Coverage Indications, Limitations, and/or Medical Necessity 
Hypoglossal nerve stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe 
obstructive sleep apnea (OSA) when all of the following criteria are met: 
 
Beneficiary is 22 years of age or older; and 
Body mass index (BMI) is less than 35 kg/m2; and 
A polysomnography (PSG) demonstrating an apnea-hypopnea index (AHI) of 15 to 65 events per hour within 
24 months of initial consultation for HNS implant; and 
Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the 
total AHI); and 
Shared Decision-Making (SDM) between the Beneficiary, Sleep physician, AND qualified otolaryngologist (if 
they are not the same) who determines that the Beneficiary demonstrates continuous positive airway pressure 
(CPAP) failure (defined as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as CPAP 
machine-derived compliance reporting with usage less than 4 hours a night for at least 70 percent of the nights 
in 1 month, or the CPAP has been returned) despite CPAP interface and/or setting optimizations. 
Confirmed absence of complete concentric collapse at the soft palate level by a drug-induced sleep endoscopy 
(DISE) procedure; and 
Absence of anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per 
standardized tonsillar hypertrophy grading scale). 
Use of HNS devices with United States (U.S.) Food and Drug Administration (FDA)-approval for implantation 
to treat OSA (e.g., Inspire II Upper Airway Stimulator ). 
HNS is not reasonable or necessary when any 1 of the following contraindications are present: 
 
Beneficiaries with central and mixed apneas that make up more than one-quarter of the total AHI 
BMI 35 kg/m2 or greater 
Neuromuscular disease 
Hypoglossal-nerve palsy Severe restrictive or obstructive pulmonary disease 
Moderate-to-severe pulmonary arterial hypertension 
Severe valvular heart disease 
New York Heart Association class III or IV heart failure 
Recent myocardial infarction or severe cardiac arrhythmias (within the past 6 months) 
Persistent uncontrolled hypertension despite medication use 
Acute psychiatric disease 
Coexisting non-respiratory sleep disorders that would confound functional sleep assessment 
Beneficiaries who are, or who plan to become pregnant 
Beneficiaries who are unable or do not have the necessary assistance to operate the device's external 
programmer 
Beneficiaries with any condition or procedure that has compromised neurological control of the upper airway 
HNS implant devices that are not compatible with magnetic resonance imaging (MRI) in Beneficiaries who 
require MRI. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Hypoglossal Nerve 
Stimulation for Obstructive Sleep Apnea (L38276). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.