Aetna Obstructive Sleep Apnea in Adults coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Attended full-channel (Type I) polysomnography (NPSG) in a healthcare facility is medically necessary to diagnose OSA in a patient with symptoms suggestive of OSA, as part of a comprehensive sleep evaluation with adequate follow-up
• Attended in-facility NPSG (rather than home testing) is REQUIRED when ANY of: moderate-to-severe pulmonary disease; neuromuscular disease; history of stroke with respiratory effects; epilepsy; congestive heart failure (NYHA class III-IV or LVEF <45%); pulmonary hypertension; chronic opioid use; or super obesity (BMI >45)
• Attended in-facility NPSG is REQUIRED when the patient has comorbid sleep disorders (ANY of: periodic limb movement disorder, parasomnias, severe insomnia, narcolepsy, or central/complex sleep apnea)
• Attended in-facility NPSG is REQUIRED when portable/home monitoring results are negative or technically inadequate
• Attended in-facility NPSG is REQUIRED in low pretest-probability cases (e.g., normal BMI, normal airway, no snoring)
• Attended in-facility NPSG is REQUIRED when the patient lacks the mobility or dexterity to use a home monitoring device
• Home (unattended) sleep apnea testing is medically necessary using a Type II, Type III, or Type IV(A) device that measures airflow plus at least 2 other channels; OR a device with at least 3 channels including pulse oximetry, actigraphy, and peripheral arterial tone
• Split-night NPSG (diagnostic study converted to CPAP titration in the same night) is medically necessary when AHI >15 is documented in the first 2 hours of the diagnostic study
• Full-night CPAP titration NPSG is medically necessary when the first 2 hours AHI is <=15, OR when a split-night study failed to eliminate most obstructive events
• Attended NPSG for CPAP titration is medically necessary in patients with persistent symptoms despite AHI <5 on CPAP with >=70% compliance
• Attended NPSG is medically necessary prior to upper airway surgical procedures for OSA
• Attended NPSG is medically necessary to evaluate candidacy for an Inspire hypoglossal-nerve-stimulation implant
• Video-EEG-NPSG is medically necessary when seizure-related sleep disruptions are suspected and standard EEG is inconclusive
• Cephalometric X-rays (pre-treatment lateral film, and a film with the appliance in place) are medically necessary for oral appliance evaluation; cephalometric X-rays are also medically necessary for surgical planning when an anterior mandibular osteotomy is planned
• CPAP / CPAP with pressure-relief (C-Flex, C-Flex+) / AutoPAP / AutoPAP with pressure-relief (A-Flex) is medically necessary when ONE of: (a) AHI >=15 events/hr (minimum 30 events); OR (b) AHI >=5 and <15 events/hr (minimum 10 events) AND at least ONE of [documented stroke; hypertension (SBP >140 or DBP >90 mmHg); ischemic heart disease; impaired cognition/mood disorder/insomnia; excessive daytime sleepiness (Epworth >10); >20 oxygen-desaturation episodes <85% O2 sat, OR any episode <70%]
• BiPAP without backup rate / BiPAP with pressure-relief (Bi-Flex) / DPAP / VPAP is medically necessary for patients intolerant to CPAP/AutoPAP or when CPAP/AutoPAP is ineffective, WITH documented proper mask-fitting trial AND documented inadequate symptom control / inadequate AHI reduction at lower pressure settings
• Oral pressure appliance (OPAP) is medically necessary on an exception basis only, for patients unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain, or claustrophobia
• PAP device replacement is medically necessary at the 5-year reasonable useful lifetime; earlier replacement is allowed for a change in medical condition (but NOT for misuse or abuse)
• Continued PAP therapy beyond the initial authorization is medically necessary when the treating physician documents symptom improvement AND adherence of >=4 hours/night on >=70% of nights during a consecutive 30-day period
• PAP accessories/supplies are medically necessary when the patient meets PAP criteria: chinstrap, disposable and non-disposable filters, full face mask, headgear, heated or non-heated humidifier, nasal interface (mask or cannula), oral interface, replacement cushions/pillows, replacement interface components, and humidifier tubing
• An upgraded face mask is medically necessary ONLY if documentation shows a need for a different mask due to inability to maintain pressure or to prevent pressure sores
• Oral appliance (mandibular advancement device or tongue-retaining device) is medically necessary when ONE of: (a) AHI >=15 events/hr (minimum 30 events); OR (b) AHI >=5 and <15 events/hr (minimum 10 events) AND documentation of at least ONE of [stroke; hypertension (SBP >140 or DBP >90 mmHg); ischemic heart disease; impaired cognition/mood disorder/insomnia; excessive daytime sleepiness (Epworth >10 or MSLT <6); >20 oxygen-desaturation episodes <85%, OR any <70%]; OR (c) AHI/RDI >30 AND (unable to tolerate PAP OR PAP contraindicated)
• Oral appliance replacement is medically necessary at the 5-year reasonable useful lifetime; earlier replacement is allowed for a change in medical condition (but NOT for misuse or abuse)
• Adult lingual or pharyngeal tonsillectomy is medically necessary for hypertrophied tonsils compromising the airway
• Tonsillectomy combined with UPPP is medically necessary when the patient meets UPPP criteria
• Adenoidectomy is medically necessary for significant nasopharyngeal obstruction due to adenoid hyperplasia
• Drug-induced sleep endoscopy (DISE) is medically necessary to evaluate appropriateness of hypoglossal nerve stimulation when multiple levels of obstruction are suspected and all hypoglossal-stimulation criteria are met
• Hypoglossal nerve stimulation with an FDA-approved system (e.g., Inspire II) is medically necessary when ALL of: (1) age >=18 years; (2) BMI <40 kg/m2; (3) PSG within 24 months of first consultation; (4) predominantly obstructive events (central/mixed apneas <25% of total AHI); (5) AHI 15-100 events/hr; (6) >=1 month of CPAP documentation showing failure (AHI >15 despite use) OR intolerance (<4 hours/night, 5 nights/week); (7) absence of complete concentric collapse at the soft palate on DISE or flexible laryngoscopy; (8) no tonsillar hypertrophy grade 3-4 and no other anatomical findings compromising device performance
• Jaw realignment surgery (hyoid myotomy/suspension, mandibular osteotomy, genioglossus advancement) is medically necessary for patients who failed other OSA treatments
• Nasal surgery is medically necessary as follows: nasal valve surgery for nasal valve collapse with CPAP intolerance related to nasal issues and high pressure requirements; turbinectomy for severe obstruction from hypertrophied turbinates; polypectomy for severe obstruction from nasal polyps; septoplasty for nasal obstruction with CPAP intolerance
• Palatopharyngoplasty (UPPP, uvulopharyngoplasty, uvulo-palatal flap, expansion pharyngoplasty, lateral pharyngoplasty, trans-palatal advancement pharyngoplasty, relocation pharyngoplasty) is medically necessary for patients who meet CPAP/AutoPAP criteria but have an inadequate response to or intolerance of CPAP/AutoPAP despite pressure and mask adjustments
• Tongue base reduction surgery (midline glossectomy, lingualplasty) is medically necessary for lower pharyngeal airway obstruction
• Tracheostomy is medically necessary for the most severe OSA not manageable by other interventions
• Repeat sleep study (up to twice yearly) is medically necessary to: assess continued PAP effectiveness with new/persistent symptoms after device interrogation; determine whether PAP settings need adjustment for new/persistent symptoms after interrogation (does NOT apply to AutoPAP); reassess after substantial weight loss (>=10% body weight) or other medical condition change affecting PAP necessity; or assess treatment response after upper airway surgery or initial oral appliance therapy
• Laser-assisted uvuloplasty (LAUP) is medically necessary, on individual case review, ONLY for patients with severe OSA who are unable to undergo UPPP and who have failed a trial of CPAP/AutoPAP and an oral appliance

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 95810·PA verdict·Rate
• 95811·PA verdict·Rate
• 42145·PA verdict·Rate
• E0601·PA verdict·Rate
• E0470·PA verdict·Rate
• E0471·PA verdict·Rate

Documentation required

• Documentation of symptoms suggestive of OSA for diagnostic testing
• Attended NPSG must be part of a comprehensive sleep evaluation with adequate follow-up
• Diagnostic sleep study based on a minimum of 2 hours of continuous recorded sleep (or shorter if total events meet threshold requirements)
• AHI/RDI calculations must include all sleep stages (not REM-only); projections of AHI/RDI based on shorter testing times or fewer events are not acceptable
• For CPAP/AutoPAP/BiPAP/DPAP/VPAP: documentation of sleep study results (facility-based NPSG, or home sleep test using a Type II, III, IV(A), or Watch-PAT device)
• For BiPAP/DPAP/VPAP/OPAP: documentation of a proper CPAP/AutoPAP mask-fitting trial and documented failure to meet therapeutic goals despite optimal therapy
• For BiPAP/DPAP/VPAP/OPAP: documentation that the current CPAP/AutoPAP pressure setting prevents tolerance and that lower settings failed to adequately control symptoms or reduce AHI/RDI
• For continued PAP therapy beyond initial authorization: face-to-face clinical reevaluation by the treating physician documenting symptom improvement
• For continued PAP therapy: objective adherence evidence (use >=4 hours/night on >=70% of nights during a consecutive 30-day period)
• For hypoglossal nerve stimulation: PSG within 24 months of implant consultation; DISE or flexible laryngoscopy documentation; and CPAP failure/intolerance documentation (>=1 month of monitoring data)
• For UPPP: medical records documenting a prior CPAP/AutoPAP attempt before surgery is considered
• For upper airway surgical procedures: confirmation of the OSA diagnosis prior to surgery
• For oral appliances: sleep test results meeting the diagnostic criteria
• For nasal valve surgery: photos clearly documenting internal or external nasal valve collapse

Frequently asked questions

When does Aetna cover Obstructive Sleep Apnea in Adults (CPT 95810), and what gets it denied?

Aetna CPB 0004 covers diagnosis and treatment of obstructive sleep apnea in adults. Diagnostic sleep testing (attended in-facility polysomnography, or home sleep testing in appropriate lower-risk patients) is covered to confirm OSA, and treatment with CPAP/AutoPAP, BiPAP, oral appliances, or surgery is covered once OSA is documented at the required severity. The key gate is the apnea-hypopnea index: AHI >=15 qualifies, or AHI 5-14 plus a listed comorbidity (e.g., stroke, hypertension, ischemic heart disease, excessive daytime sleepiness), with PAP/oral appliances generally tried before most surgical options; a large list of alternative devices, biomarkers, and procedures is considered experimental/investigational. Coverage criteria include: Attended full-channel (Type I) polysomnography (NPSG) in a healthcare facility is medically necessary to diagnose OSA in a patient with symptoms suggestive of OSA, as part of a comprehensive sleep evaluation with adequate follow-up; Attended in-facility NPSG (rather than home testing) is REQUIRED when ANY of: moderate-to-severe pulmonary disease; neuromuscular disease; history of stroke with respiratory effects; epilepsy; congestive heart failure (NYHA class III-IV or LVEF <45%); pulmonary hypertension; chronic opioid use; or super obesity (BMI >45); Attended in-facility NPSG is REQUIRED when the patient has comorbid sleep disorders (ANY of: periodic limb movement disorder, parasomnias, severe insomnia, narcolepsy, or central/complex sleep apnea); Attended in-facility NPSG is REQUIRED when portable/home monitoring results are negative or technically inadequate; Attended in-facility NPSG is REQUIRED in low pretest-probability cases (e.g., normal BMI, normal airway, no snoring); Attended in-facility NPSG is REQUIRED when the patient lacks the mobility or dexterity to use a home monitoring device; Home (unattended) sleep apnea testing is medically necessary using a Type II, Type III, or Type IV(A) device that measures airflow plus at least 2 other channels; OR a device with at least 3 channels including pulse oximetry, actigraphy, and peripheral arterial tone; Split-night NPSG (diagnostic study converted to CPAP titration in the same night) is medically necessary when AHI >15 is documented in the first 2 hours of the diagnostic study; Full-night CPAP titration NPSG is medically necessary when the first 2 hours AHI is <=15, OR when a split-night study failed to eliminate most obstructive events; Attended NPSG for CPAP titration is medically necessary in patients with persistent symptoms despite AHI <5 on CPAP with >=70% compliance; Attended NPSG is medically necessary prior to upper airway surgical procedures for OSA; Attended NPSG is medically necessary to evaluate candidacy for an Inspire hypoglossal-nerve-stimulation implant; Video-EEG-NPSG is medically necessary when seizure-related sleep disruptions are suspected and standard EEG is inconclusive; Cephalometric X-rays (pre-treatment lateral film, and a film with the appliance in place) are medically necessary for oral appliance evaluation; cephalometric X-rays are also medically necessary for surgical planning when an anterior mandibular osteotomy is planned; CPAP / CPAP with pressure-relief (C-Flex, C-Flex+) / AutoPAP / AutoPAP with pressure-relief (A-Flex) is medically necessary when ONE of: (a) AHI >=15 events/hr (minimum 30 events); OR (b) AHI >=5 and <15 events/hr (minimum 10 events) AND at least ONE of [documented stroke; hypertension (SBP >140 or DBP >90 mmHg); ischemic heart disease; impaired cognition/mood disorder/insomnia; excessive daytime sleepiness (Epworth >10); >20 oxygen-desaturation episodes <85% O2 sat, OR any episode <70%]; BiPAP without backup rate / BiPAP with pressure-relief (Bi-Flex) / DPAP / VPAP is medically necessary for patients intolerant to CPAP/AutoPAP or when CPAP/AutoPAP is ineffective, WITH documented proper mask-fitting trial AND documented inadequate symptom control / inadequate AHI reduction at lower pressure settings; Oral pressure appliance (OPAP) is medically necessary on an exception basis only, for patients unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain, or claustrophobia; PAP device replacement is medically necessary at the 5-year reasonable useful lifetime; earlier replacement is allowed for a change in medical condition (but NOT for misuse or abuse); Continued PAP therapy beyond the initial authorization is medically necessary when the treating physician documents symptom improvement AND adherence of >=4 hours/night on >=70% of nights during a consecutive 30-day period; PAP accessories/supplies are medically necessary when the patient meets PAP criteria: chinstrap, disposable and non-disposable filters, full face mask, headgear, heated or non-heated humidifier, nasal interface (mask or cannula), oral interface, replacement cushions/pillows, replacement interface components, and humidifier tubing; An upgraded face mask is medically necessary ONLY if documentation shows a need for a different mask due to inability to maintain pressure or to prevent pressure sores; Oral appliance (mandibular advancement device or tongue-retaining device) is medically necessary when ONE of: (a) AHI >=15 events/hr (minimum 30 events); OR (b) AHI >=5 and <15 events/hr (minimum 10 events) AND documentation of at least ONE of [stroke; hypertension (SBP >140 or DBP >90 mmHg); ischemic heart disease; impaired cognition/mood disorder/insomnia; excessive daytime sleepiness (Epworth >10 or MSLT <6); >20 oxygen-desaturation episodes <85%, OR any <70%]; OR (c) AHI/RDI >30 AND (unable to tolerate PAP OR PAP contraindicated); Oral appliance replacement is medically necessary at the 5-year reasonable useful lifetime; earlier replacement is allowed for a change in medical condition (but NOT for misuse or abuse); Adult lingual or pharyngeal tonsillectomy is medically necessary for hypertrophied tonsils compromising the airway; Tonsillectomy combined with UPPP is medically necessary when the patient meets UPPP criteria; Adenoidectomy is medically necessary for significant nasopharyngeal obstruction due to adenoid hyperplasia; Drug-induced sleep endoscopy (DISE) is medically necessary to evaluate appropriateness of hypoglossal nerve stimulation when multiple levels of obstruction are suspected and all hypoglossal-stimulation criteria are met; Hypoglossal nerve stimulation with an FDA-approved system (e.g., Inspire II) is medically necessary when ALL of: (1) age >=18 years; (2) BMI <40 kg/m2; (3) PSG within 24 months of first consultation; (4) predominantly obstructive events (central/mixed apneas <25% of total AHI); (5) AHI 15-100 events/hr; (6) >=1 month of CPAP documentation showing failure (AHI >15 despite use) OR intolerance (<4 hours/night, 5 nights/week); (7) absence of complete concentric collapse at the soft palate on DISE or flexible laryngoscopy; (8) no tonsillar hypertrophy grade 3-4 and no other anatomical findings compromising device performance; Jaw realignment surgery (hyoid myotomy/suspension, mandibular osteotomy, genioglossus advancement) is medically necessary for patients who failed other OSA treatments; Nasal surgery is medically necessary as follows: nasal valve surgery for nasal valve collapse with CPAP intolerance related to nasal issues and high pressure requirements; turbinectomy for severe obstruction from hypertrophied turbinates; polypectomy for severe obstruction from nasal polyps; septoplasty for nasal obstruction with CPAP intolerance; Palatopharyngoplasty (UPPP, uvulopharyngoplasty, uvulo-palatal flap, expansion pharyngoplasty, lateral pharyngoplasty, trans-palatal advancement pharyngoplasty, relocation pharyngoplasty) is medically necessary for patients who meet CPAP/AutoPAP criteria but have an inadequate response to or intolerance of CPAP/AutoPAP despite pressure and mask adjustments; Tongue base reduction surgery (midline glossectomy, lingualplasty) is medically necessary for lower pharyngeal airway obstruction; Tracheostomy is medically necessary for the most severe OSA not manageable by other interventions; Repeat sleep study (up to twice yearly) is medically necessary to: assess continued PAP effectiveness with new/persistent symptoms after device interrogation; determine whether PAP settings need adjustment for new/persistent symptoms after interrogation (does NOT apply to AutoPAP); reassess after substantial weight loss (>=10% body weight) or other medical condition change affecting PAP necessity; or assess treatment response after upper airway surgery or initial oral appliance therapy; Laser-assisted uvuloplasty (LAUP) is medically necessary, on individual case review, ONLY for patients with severe OSA who are unable to undergo UPPP and who have failed a trial of CPAP/AutoPAP and an oral appliance. Applies to 6 codes: 95810, 95811, 42145, E0601, E0470, E0471. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation of symptoms suggestive of OSA for diagnostic testing; Attended NPSG must be part of a comprehensive sleep evaluation with adequate follow-up; Diagnostic sleep study based on a minimum of 2 hours of continuous recorded sleep (or shorter if total events meet threshold requirements); AHI/RDI calculations must include all sleep stages (not REM-only); projections of AHI/RDI based on shorter testing times or fewer events are not acceptable; For CPAP/AutoPAP/BiPAP/DPAP/VPAP: documentation of sleep study results (facility-based NPSG, or home sleep test using a Type II, III, IV(A), or Watch-PAT device); For BiPAP/DPAP/VPAP/OPAP: documentation of a proper CPAP/AutoPAP mask-fitting trial and documented failure to meet therapeutic goals despite optimal therapy; For BiPAP/DPAP/VPAP/OPAP: documentation that the current CPAP/AutoPAP pressure setting prevents tolerance and that lower settings failed to adequately control symptoms or reduce AHI/RDI; For continued PAP therapy beyond initial authorization: face-to-face clinical reevaluation by the treating physician documenting symptom improvement; For continued PAP therapy: objective adherence evidence (use >=4 hours/night on >=70% of nights during a consecutive 30-day period); For hypoglossal nerve stimulation: PSG within 24 months of implant consultation; DISE or flexible laryngoscopy documentation; and CPAP failure/intolerance documentation (>=1 month of monitoring data); For UPPP: medical records documenting a prior CPAP/AutoPAP attempt before surgery is considered; For upper airway surgical procedures: confirmation of the OSA diagnosis prior to surgery; For oral appliances: sleep test results meeting the diagnostic criteria; For nasal valve surgery: photos clearly documenting internal or external nasal valve collapse. Policy exclusions and limitations: Acoustic pharyngometry is experimental/investigational for OSA; Actigraphy testing used alone is experimental/investigational for OSA; AirLift procedure for tongue suspension is experimental/investigational; Cephalographic X-rays beyond the standard pre-treatment and appliance-in-place films are not medically necessary; Daytime nap polysomnography is experimental/investigational; Diagnostic audio recording, with or without pulse oximetry, is experimental/investigational for OSA; DISE used for treatment of tracheomalacia is experimental/investigational; Dynamic sleep MRI for OSA diagnosis is experimental/investigational; Elevoplasty (Elevo Palatal Implant System) is experimental/investigational; Evaluation of gut microbiota for OSA management is experimental/investigational; Genetic association studies (e.g., TNFA, ACE gene, ApoE polymorphism) for OSA are experimental/investigational; Laryngeal function studies for OSA are experimental/investigational; Maintenance of wakefulness test for OSA is experimental/investigational; C-reactive protein blood levels as a biomarker for OSA is experimental/investigational; Interleukin-8 blood levels as a biomarker for OSA is experimental/investigational; Leptin blood levels as a biomarker for OSA is experimental/investigational; Central corneal thickness, intra-ocular pressure, and retinal nerve fiber layer measurements for grading OSAS severity are experimental/investigational; Circulating malondialdehyde concentrations as a biomarker for OSA is experimental/investigational; Fas-positive lymphocytes for evaluation of systemic inflammation in OSA is experimental/investigational; Interleukin-6 blood levels as a biomarker for OSA is experimental/investigational; Tumor necrosis factor-alpha blood levels as a biomarker for OSA is experimental/investigational; Brain-derived neurotrophic factor (BDNF) blood levels as a biomarker for OSA is experimental/investigational; Insulin-like growth factor 1 (IGF-1) blood levels as a biomarker for OSA is experimental/investigational; Monocyte chemoattractant protein-1 (MCP-1) blood levels as a biomarker for OSA is experimental/investigational; Multiple sleep latency test (MSLT) for OSA is experimental/investigational; Natural sleep endoscopy for OSA is experimental/investigational; Quantitative susceptibility mapping of brain iron levels for OSA is experimental/investigational; Screening for asymptomatic OSA is experimental/investigational / not medically necessary; SleepStrip is experimental/investigational; Sonography for OSA diagnosis is experimental/investigational; Static charge sensitive bed for OSA is experimental/investigational; Tomographic X-ray for OSA is experimental/investigational; Upper gastrointestinal endoscopy for OSAS diagnosis is experimental/investigational; Advanced glycation end-products serum levels as a biomarker for OSA is experimental/investigational; Voxel-based brain morphometry (VBM) studies for OSA are experimental/investigational; Temporomandibular joint or sella turcica X-rays for OSA are experimental/investigational / not medically necessary; BiPAP with a backup rate feature (adaptive servoventilation, e.g., VPAP Adapt SV) is experimental/investigational for OSA; C.A.R.E. Appliances (DNA, mRNA, mmRNA variants) are experimental/investigational; Daytime neuromuscular stimulation of the tongue (eXciteOSA) is experimental/investigational; Expiratory muscle strength training for OSA is experimental/investigational; Oral appliances for upper airway resistance syndrome (UARS) are experimental/investigational; Oral appliances for indications other than OSA are experimental/investigational / not medically necessary; Positive airway pressure for treatment of upper airway resistance syndrome (UARS) is experimental/investigational; PAP for improvement of seizure control in epilepsy patients is experimental/investigational; Apnea-triggered muscle stimulation is experimental/investigational; Cardiac (atrial) pacing for OSA is experimental/investigational; Cautery-assisted palatal stiffening operation (CAPSO) is experimental/investigational; Sternothyroid muscle contraction with ansa cervicalis stimulation is experimental/investigational; Positional therapy devices (e.g., Lunoa System, Zzoma positional device) are experimental/investigational; Endoscopically-assisted surgical expansion (EASE) is experimental/investigational; Epiglottidectomy / partial epiglottidectomy for OSA is experimental/investigational; Genioplasty and genial tubercle advancement for OSA are experimental/investigational; Injection snoreplasty (sclerosing agent injection into the soft palate) is experimental/investigational; Mandibular distraction osteogenesis for OSA is experimental/investigational; Nasal dilators are experimental/investigational / not medically necessary for OSA; Nasal expiratory positive airway pressure (EPAP) devices (e.g., Provent, ULTepap) are experimental/investigational; NightLase laser therapy for snoring or OSA is experimental/investigational; Pillar Palatal Implant System is experimental/investigational; Rapid maxillary expansion for OSA is experimental/investigational; Remotely controlled mandibular positioner used as a screening tool is experimental/investigational; Respiratory muscle therapy (breathing exercises, oropharyngeal exercises, playing wind instruments) for OSA is experimental/investigational; Somnoplasty (radiofrequency ablation of tongue base, uvula, or soft palate) is experimental/investigational; Coblation (radiofrequency ablation of nasal passages and soft palate) is experimental/investigational; Surgical palatal expansion for OSA is experimental/investigational; Advance System (adjustable tongue-advancement device) is experimental/investigational; AIRvance Tongue Suspension (formerly Repose) System is experimental/investigational; Encore Tongue Base Suspension is experimental/investigational; Winx Therapy System / oral pressure therapy is experimental/investigational; Transcutaneous electrical nerve stimulation (TENS) for OSA is experimental/investigational; Cold knife uvulectomy for OSA is experimental/investigational; Laser-assisted uvuloplasty (LAUP) is experimental/investigational EXCEPT, on individual case review, for severe OSA patients unable to undergo UPPP who have failed CPAP/AutoPAP and an oral appliance; Hypoglossal nerve stimulation using non-FDA-approved systems (Apnex HGNS, aura6000, ImThera Targeted Hypoglossal Neuro-stimulation, WellStar upper airway neuro-stimulation) is experimental/investigational; Palatopharyngoplasty for non-obstructive sleep apnea or for UARS is not medically necessary / experimental-investigational; Treatment of snoring alone, without significant OSA, is not medically necessary; Positive airway pressure bed pillows are not medically necessary; Batteries for PAP devices are not medically necessary; DC adapters for PAP devices are not medically necessary; Replacement PAP equipment without an indication for repeat testing is not medically necessary; Oral appliances for snoring (e.g., Slow Wave DS8, Snore Guard) are not medically necessary; Compliance monitors for oral appliances are not medically necessary; PAP device replacement due to misuse or abuse is not covered; Oral appliance replacement due to misuse or abuse is not covered; Home sleep study devices that do not measure AHI and oxygen saturation (e.g., BiancaMed SleepMinder, SNAP with <3 channels, SleepImage Sleep Quality Screener) are not medically necessary; Repeat home sleep testing on multiple consecutive nights is not medically necessary; Orthodontic therapy (placed with jaw realignment surgery) is excluded under standard medical plans; Dental rehabilitation services (dentures, bridgework) for OSA treatment are not covered under standard medical plans; AM Aligner (adjustable positioning dental device) is considered inclusive to the sleep appliance and not separately covered. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Obstructive Sleep Apnea in Adults?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation of symptoms suggestive of OSA for diagnostic testing; Attended NPSG must be part of a comprehensive sleep evaluation with adequate follow-up; Diagnostic sleep study based on a minimum of 2 hours of continuous recorded sleep (or shorter if total events meet threshold requirements); AHI/RDI calculations must include all sleep stages (not REM-only); projections of AHI/RDI based on shorter testing times or fewer events are not acceptable; For CPAP/AutoPAP/BiPAP/DPAP/VPAP: documentation of sleep study results (facility-based NPSG, or home sleep test using a Type II, III, IV(A), or Watch-PAT device); For BiPAP/DPAP/VPAP/OPAP: documentation of a proper CPAP/AutoPAP mask-fitting trial and documented failure to meet therapeutic goals despite optimal therapy; For BiPAP/DPAP/VPAP/OPAP: documentation that the current CPAP/AutoPAP pressure setting prevents tolerance and that lower settings failed to adequately control symptoms or reduce AHI/RDI; For continued PAP therapy beyond initial authorization: face-to-face clinical reevaluation by the treating physician documenting symptom improvement; For continued PAP therapy: objective adherence evidence (use >=4 hours/night on >=70% of nights during a consecutive 30-day period); For hypoglossal nerve stimulation: PSG within 24 months of implant consultation; DISE or flexible laryngoscopy documentation; and CPAP failure/intolerance documentation (>=1 month of monitoring data); For UPPP: medical records documenting a prior CPAP/AutoPAP attempt before surgery is considered; For upper airway surgical procedures: confirmation of the OSA diagnosis prior to surgery; For oral appliances: sleep test results meeting the diagnostic criteria; For nasal valve surgery: photos clearly documenting internal or external nasal valve collapse.

What does Aetna exclude for Obstructive Sleep Apnea in Adults?

Policy exclusions and limitations: Acoustic pharyngometry is experimental/investigational for OSA; Actigraphy testing used alone is experimental/investigational for OSA; AirLift procedure for tongue suspension is experimental/investigational; Cephalographic X-rays beyond the standard pre-treatment and appliance-in-place films are not medically necessary; Daytime nap polysomnography is experimental/investigational; Diagnostic audio recording, with or without pulse oximetry, is experimental/investigational for OSA; DISE used for treatment of tracheomalacia is experimental/investigational; Dynamic sleep MRI for OSA diagnosis is experimental/investigational; Elevoplasty (Elevo Palatal Implant System) is experimental/investigational; Evaluation of gut microbiota for OSA management is experimental/investigational; Genetic association studies (e.g., TNFA, ACE gene, ApoE polymorphism) for OSA are experimental/investigational; Laryngeal function studies for OSA are experimental/investigational; Maintenance of wakefulness test for OSA is experimental/investigational; C-reactive protein blood levels as a biomarker for OSA is experimental/investigational; Interleukin-8 blood levels as a biomarker for OSA is experimental/investigational; Leptin blood levels as a biomarker for OSA is experimental/investigational; Central corneal thickness, intra-ocular pressure, and retinal nerve fiber layer measurements for grading OSAS severity are experimental/investigational; Circulating malondialdehyde concentrations as a biomarker for OSA is experimental/investigational; Fas-positive lymphocytes for evaluation of systemic inflammation in OSA is experimental/investigational; Interleukin-6 blood levels as a biomarker for OSA is experimental/investigational; Tumor necrosis factor-alpha blood levels as a biomarker for OSA is experimental/investigational; Brain-derived neurotrophic factor (BDNF) blood levels as a biomarker for OSA is experimental/investigational; Insulin-like growth factor 1 (IGF-1) blood levels as a biomarker for OSA is experimental/investigational; Monocyte chemoattractant protein-1 (MCP-1) blood levels as a biomarker for OSA is experimental/investigational; Multiple sleep latency test (MSLT) for OSA is experimental/investigational; Natural sleep endoscopy for OSA is experimental/investigational; Quantitative susceptibility mapping of brain iron levels for OSA is experimental/investigational; Screening for asymptomatic OSA is experimental/investigational / not medically necessary; SleepStrip is experimental/investigational; Sonography for OSA diagnosis is experimental/investigational; Static charge sensitive bed for OSA is experimental/investigational; Tomographic X-ray for OSA is experimental/investigational; Upper gastrointestinal endoscopy for OSAS diagnosis is experimental/investigational; Advanced glycation end-products serum levels as a biomarker for OSA is experimental/investigational; Voxel-based brain morphometry (VBM) studies for OSA are experimental/investigational; Temporomandibular joint or sella turcica X-rays for OSA are experimental/investigational / not medically necessary; BiPAP with a backup rate feature (adaptive servoventilation, e.g., VPAP Adapt SV) is experimental/investigational for OSA; C.A.R.E. Appliances (DNA, mRNA, mmRNA variants) are experimental/investigational; Daytime neuromuscular stimulation of the tongue (eXciteOSA) is experimental/investigational; Expiratory muscle strength training for OSA is experimental/investigational; Oral appliances for upper airway resistance syndrome (UARS) are experimental/investigational; Oral appliances for indications other than OSA are experimental/investigational / not medically necessary; Positive airway pressure for treatment of upper airway resistance syndrome (UARS) is experimental/investigational; PAP for improvement of seizure control in epilepsy patients is experimental/investigational; Apnea-triggered muscle stimulation is experimental/investigational; Cardiac (atrial) pacing for OSA is experimental/investigational; Cautery-assisted palatal stiffening operation (CAPSO) is experimental/investigational; Sternothyroid muscle contraction with ansa cervicalis stimulation is experimental/investigational; Positional therapy devices (e.g., Lunoa System, Zzoma positional device) are experimental/investigational; Endoscopically-assisted surgical expansion (EASE) is experimental/investigational; Epiglottidectomy / partial epiglottidectomy for OSA is experimental/investigational; Genioplasty and genial tubercle advancement for OSA are experimental/investigational; Injection snoreplasty (sclerosing agent injection into the soft palate) is experimental/investigational; Mandibular distraction osteogenesis for OSA is experimental/investigational; Nasal dilators are experimental/investigational / not medically necessary for OSA; Nasal expiratory positive airway pressure (EPAP) devices (e.g., Provent, ULTepap) are experimental/investigational; NightLase laser therapy for snoring or OSA is experimental/investigational; Pillar Palatal Implant System is experimental/investigational; Rapid maxillary expansion for OSA is experimental/investigational; Remotely controlled mandibular positioner used as a screening tool is experimental/investigational; Respiratory muscle therapy (breathing exercises, oropharyngeal exercises, playing wind instruments) for OSA is experimental/investigational; Somnoplasty (radiofrequency ablation of tongue base, uvula, or soft palate) is experimental/investigational; Coblation (radiofrequency ablation of nasal passages and soft palate) is experimental/investigational; Surgical palatal expansion for OSA is experimental/investigational; Advance System (adjustable tongue-advancement device) is experimental/investigational; AIRvance Tongue Suspension (formerly Repose) System is experimental/investigational; Encore Tongue Base Suspension is experimental/investigational; Winx Therapy System / oral pressure therapy is experimental/investigational; Transcutaneous electrical nerve stimulation (TENS) for OSA is experimental/investigational; Cold knife uvulectomy for OSA is experimental/investigational; Laser-assisted uvuloplasty (LAUP) is experimental/investigational EXCEPT, on individual case review, for severe OSA patients unable to undergo UPPP who have failed CPAP/AutoPAP and an oral appliance; Hypoglossal nerve stimulation using non-FDA-approved systems (Apnex HGNS, aura6000, ImThera Targeted Hypoglossal Neuro-stimulation, WellStar upper airway neuro-stimulation) is experimental/investigational; Palatopharyngoplasty for non-obstructive sleep apnea or for UARS is not medically necessary / experimental-investigational; Treatment of snoring alone, without significant OSA, is not medically necessary; Positive airway pressure bed pillows are not medically necessary; Batteries for PAP devices are not medically necessary; DC adapters for PAP devices are not medically necessary; Replacement PAP equipment without an indication for repeat testing is not medically necessary; Oral appliances for snoring (e.g., Slow Wave DS8, Snore Guard) are not medically necessary; Compliance monitors for oral appliances are not medically necessary; PAP device replacement due to misuse or abuse is not covered; Oral appliance replacement due to misuse or abuse is not covered; Home sleep study devices that do not measure AHI and oxygen saturation (e.g., BiancaMed SleepMinder, SNAP with <3 channels, SleepImage Sleep Quality Screener) are not medically necessary; Repeat home sleep testing on multiple consecutive nights is not medically necessary; Orthodontic therapy (placed with jaw realignment surgery) is excluded under standard medical plans; Dental rehabilitation services (dentures, bridgework) for OSA treatment are not covered under standard medical plans; AM Aligner (adjustable positioning dental device) is considered inclusive to the sleep appliance and not separately covered. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

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• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT