Sleep-Disordered Breathing, often referred to as Obstructive Sleep Apnea
(OSA), is characterized by frequent episodes of hypopnea or apnea during
sleep. Multiple detrimental physiologic changes may result from these
hypopneic and apneic episodes. Non-surgical and surgical approaches to
obstructive apnea and hypopnea have been developed.

Continuous Positive Airway Pressure (CPAP) breathing is the treatment of
choice for OSA. Some patients do not tolerate CPAP or are not benefited from
it. The level of obstruction in OSA (retropalatal, retrolingual, and
retropalatal and retrolingual) is variable.

Uvulopalatopharyngoplasty (UPPP) is an accepted means of surgical treatment
for this disorder but is curative in less than 50% of patients. Scientific
evidence suggests that UPPP is useful in retropalatal and combination
retropalatal and retrolingual obstruction.

Mandibular Maxillary Osteotomy and Advancement is a procedure developed for
those patients with retrolingual obstruction, or those patients with
retropalatal and retrolingual obstruction who have not responded to CPAP and
uvulopalatopharyngoplasty. Medical data on the efficacy of this treatment has
been reported from only a small number of centers, but the information appears
to show good results for those patients who meet certain criteria. It is
unknown whether the technique will result in similar results outside
specialized centers.

Tracheostomy remains the surgical approach with the greatest effectiveness
since it bypasses all areas of obstruction in the nasal, palatal, lingual, and
pharyngeal areas. However, tracheostomy is associated with significant
morbidity, and is usually reserved for patients who have failed other medical
or surgical methods of treatment, or who are unsuitable for other methods of
treatment for various reasons.

Various other anatomic abnormalities (such as, but not limited to, enlarged
tonsils or tongue) sometimes cause OSA also. Surgical approaches to these
abnormalities will vary according to the anatomic defect and the
procedure/procedures needed to correct the defined problem.

Genioglossal advancement, with or without resuspension of the hyoid bone, may
be performed with uvulopalatopharyngoplasty, but this procedure is not always
successful, and there is little definitive information on its benefit.

  1. Uvulopalatopharyngoplasty (UPPP) is covered for those patients who have **all** of the following: 
    1. Obstructive sleep apnea diagnosed (prior to any proposed surgery) in a certified sleep disorders laboratory (certification body recognized by the American Academy of Sleep Medicine);
    2. A Respiratory Disturbance Index of 15 or higher;
    3. Failed to respond to Continuous Positive Airway Pressure therapy or cannot tolerate CPAP or other appropriate non-invasive treatment;
    4. Documented counseling by a physician, with recognized training in sleep disorders, about the potential benefits and risks of the surgery; **and**
    5. Evidence of retropalatal or combination retropalatal/retrolingual obstruction as the cause of the obstructive sleep apnea.
  2. Mandibular Maxillary Osteotomy and Advancement and /or genioglossus advancement with or without hyoid suspension is covered for those patients who have **all** of the following: 
    1. Obstructive sleep apnea diagnosed (prior to any proposed surgery) in a certified sleep disorders laboratory (certification body recognized by the American Academy of Sleep Medicine);
    2. A Respiratory Disturbance Index of 15 or higher;
    3. Failed to respond to Continuous Positive Airway Pressure therapy or cannot tolerate CPAP or other appropriate non-invasive treatment;
    4. Documented counseling by a physician, with recognized training in sleep disorders, about the potential benefits and risks of the surgery; **and**
    5. Evidence of retrolingual obstruction as the cause of the obstructive sleep apnea, or previous failure of UPPP to correct the obstructive sleep apnea.  
Regarding the Mandibular Maxillary Osteotomy and Advancement operation:

      1. Separate repositioning of teeth would not be necessary except under unusual circumstances; but if necessary, the dental work would be covered.
      2. Application of an interdental fixation device is occasionally necessary and is a covered service (see Documentation Requirements).
  3. Tracheostomy is covered for obstructive sleep apnea that is in the judgment of the attending physician, unresponsive to other means of treatment or in cases where other means of treatment would be ineffective or not indicated.
  4. When obstructive sleep apnea is caused by discrete anatomic abnormalities of the upper airway (such as, but not limited to, enlarged tonsils or an enlarged tongue), surgery to correct these abnormalities is covered if medically necessary based on adequate documentation in the medical records supporting the significant contribution of these abnormalities to OSA. Submucous radiofrequency reduction of hypertrophied turbinates is covered as an appropriate treatment for nasal obstruction due to turbinate hypertrophy that significantly contributes to OSA or significantly compromises CPAP therapy.
  5. The following procedures are not covered at this time. 
    1. Laser-assisted uvulopalatoplasty (LAUP) is not covered at this time since it is not considered effective for OSA.
    2. SomnoplastyTM is a trade name for palate reduction with the SomnoplastyTM System of Somnus Medical Systems. This is not a term recognized by this Contractor as a covered procedure under Medicare Part B. 
    3. The Pillar ProcedureTM is a trade name for palatal implants. Palatal implants have not  been shown effective for the treatment of obstructive sleep apnea and are not covered.
    4. Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session. will be denied as investigational and experimental.

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