On March 1, 2024, United HealthCare (UHC) revised its commercial and individual exchange medical policy for obstructive and central sleep apnea (OSA) treatment, introducing new patient eligibility requirements that could impact your practice.
The revisions are primarily for the surgical treatment of OSA and include the following:
- The criteria for implantable nerve stimulation in adults with moderate to severe OSA has been amended to include a failure of an adequate trial of oral appliance therapy.
- The body mass index (BMI) requirement has gone from 32 to 40.
- The apnea-hypopnea index (AHI) has increased from ≥ 20 and ≤ 65to an AHI of ≥ 20 and ≤ 100as determined by an attended sleep study.
Including a failed trial of an oral appliance in the criteria indicates that the industry is shifting to recognizing an oral appliance as a treatment option for OSA before surgical intervention. However, concerns exist with oral appliances when it comes to access to care and the cost of the devices.
An oral device is classified as durable medical equipment (DME), but not all dentists are Medicare DME-certified, nor do all dentists participate with medical insurance. In addition, the coverage for oral appliances is usually in the medical portion of the patient’s benefit, not the dental insurance. These factors could force patients to pay for their oral device out of pocket or, if they can’t afford it, forgo getting one altogether.
New Criteria for Adolescents With Down Syndrome
UHC recognizes that adolescents with Down syndrome have an increased risk of developing OSA, with obesity being a contributing factor. The revised UHC policy added criteria for adolescents ages 10–18 with Down syndrome to have access to implantable hypoglossal nerve stimulation, a surgical intervention. The criterion in the medical policy is a robust list in that the patient must meet all the requirements to be a surgical candidate.
The medical necessity criteria for the surgical treatment of OSA in adolescent Down syndrome patients include the following:
- Diagnosis of severe OSA (as determined by a polysomnogram within the last 24 months and an AHI ≥10 and RDI ≤50 events per hour)
- BMI < 95th percentile for age
- Total AHI < 25% for central + mixed apneas
- Contraindication for or not effectively treated with a prior adenotonsillectomy
- If the patient refuses CPAP therapy, documentation of the refusal must be supplied.
- Absence of tracheostomy use during sleep
- Absence of a complete blockage or concentric collapse of the soft palate confirmed by a medication-induced sleep endoscopy test
- Individual and caregiver refusal of a middle meningeal artery (MMA) procedure for non-concentric palatal collapse
- Used in accordance with FDA guidelines
If you have a patient who does not meet all the criteria above, you should still submit the paperwork for the preauthorization or predetermination. If United HealthCare denies it, ask for a peer-to-peer review. This is a way for the insurance company to receive feedback on opportunities to tweak the policy in future updates.
Looking Ahead and How Fuel Can Help
In the coming months, it will be interesting to see if other insurers will follow suit with oral devices as a treatment option before considering surgery for OSA. Also, will the UHC medical necessity criteria be a roadblock for adolescent Down syndrome patients to access needed OSA surgical intervention? Time will tell. Need help keeping up with the latest insurance policy changes so that you can make your billing and coding as accurate as possible? Michelle Netoskie, Fuel Medical’s Billing and Coding Specialist, offers revenue cycle management support to ensure your practice is compliant and profitable. Get in touch with her by completing the form on this page.