Beginning on Nov. 1, 2020, Harvard Pilgrim will cover hypoglossal nerve stimulation with prior authorization for commercial plans, for the treatment of moderate-to-severe obstructive sleep apnea (OSA) in patients 22 and older for whom continuous positive airway pressure (CPAP) therapy has failed.
Our new Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea Medical Policy outlines prior authorization criteria and coverage exclusions. Harvard Pilgrim will cover hypoglossal nerve stimulation for adults with moderate-to-severe OSA when documentation confirms ALL of the following:
- Member is 22 years of age or older; AND
- Body Mass Index (BMI) is ≤ 32 kg/m2; AND
- A polysomnography (PSG) is performed within 24 months of the first consultation for HGNS implant; AND
- Apnea hypopnea index (AHI) is 20 to 65 events per hour; AND
- Member has demonstrated CPAP failure for minimum of one month (residual AHI ≥ 20 or failure to use CPAP ≥ 4 hours per night for ≥ 5 nights per week) or documentation confirming inability to tolerate CPAP
- Absence of complete concentric collapse at the soft palate level as seen on a drug induced sleep endoscopy (DISE)
- No anatomical findings that would compromise performance of the device
Refer to the policy for complete criteria. To bill for hypoglossal nerve stimulation, you will need to report CPT code 64568 (Incision for implantation of cranial nerve [e.g., vagus nerve] neurostimulator electrode array and pulse generator) along with the add-on on code 0466T (Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator [list separately in addition to code for primary procedure]). Please note that 0466T requires prior authorization and will only be reimbursed when accompanied by 64568.
For more information, please refer to Harvard Pilgrim’s new Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea Medical Policy.
Director, Network Operations