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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 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 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 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 one 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. HNS devices with FDA-approval for implantation to treat OSA: Inspire II Upper Airway Stimulator. 
Summary of Safety and Effectiveness Data. PMA No. P130008; Inspire Upper Airway Stimulation (UAS) 
System, Model 3028 IPG, P130008/S016; Inspire Upper Airway Stimulation (UAS) System, Model 3028 
IPG, PMA No. P130008/S021.  
 
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 
 
NOTE: Beneficiaries with certain HNS devices can undergo MRI of the head and extremities if certain 
conditions and precautions are met. Please refer to the Manufacturer Guidelines for the relevant model for more 
information. You can find this rule in the 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.