Subject: Obstructive Sleep Apnea
Reviewed: October 19, 2015
This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:
- Clinical outcome studies in peer-reviewed published medical and dental literature
- Regulatory status of the technology
- Evidence-based guidelines of public health and health research agencies
- Evidence-based guidelines and positions of leading national health professional organizations
- Views of physicians and dentists practicing in relevant clinical areas
- Other relevant factors
We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.
Each benefits plan defines which services are covered, which are excluded and which are subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.
Medical Clinical Policy Bulletin 0004
The Obstructive Sleep Apnea in Adults medical policy bulletin was revised on September 9, 2015. This CPB is revised to state: 1) adult lingual or pharyngeal tonsillectomy, as an isolated procedure, is considered experimental and investigational for the treatment of adult OSA; 2) adult tonsillectomy is considered medically necessary for UPPP for adult OSA where the tonsils compromise the airway space; 3) an adenoidectomy is considered medically necessary where adenoid hyperplasia results in significant nasopharyngeal obstruction; 4) a single panoramic x-ray of the jaws and a lateral cephalometric x-ray are considered medically necessary for the evaluation for an oral appliance for OSA; 5) a second lateral cephalometric x-ray with the bite registration or oral appliance in place is considered medically necessary to visualize the mandibular repositioning and the changes in the airway space; 6) turbinectomy is considered medically necessary for severe nasal obstruction due to hypertrophied inferior nasal turbinates; 7) polypectomy is considered medically necessary for severe nasal obstruction due to nasal polyps; and 8) uvulectomy is considered medically necessary for neoplasm of uvula.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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