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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 state that 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: 1. Beneficiary is 22 years of age or older; and 2. Body mass index (BMI) is less than 35 kg/m2 ; and 3. 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 4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the total AHI); and 5. 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% of the nights in 1 month or the CPAP has been returned) despite CPAP interface and/or setting optimizations. 6. Confirmed absence of complete concentric collapse at the soft palate level by a drug-induced sleep endoscopy (DISE) procedure; and 7. Absence of anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per standardized tonsillar hypertrophy grading scale). 8. Use of HNS devices with Food & Drug Administration (FDA)-approval for implantation to treat OSA (e.g., Inspire II Upper Airway Stimulator). HNS is not reasonable or necessary when any one 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 these rules in 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.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.