Surgical Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS)
Uvulopalatopharyngoplasty (UPPP) may be considered medically necessary for the treatment of clinically significant obstructive sleep apnea syndrome (OSA) in appropriately selected adult patients who have not responded to or do not tolerate nasal continuous positive airway pressure (CPAP). Clinically significant OSA in this case is defined as those patients who have:
• Apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour, or
• AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA), may be considered medically necessary in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP. Clinically significant OSA in this case is defined as those patients who have:
• AHI or RDI greater than or equal to 15 events per hour, or
• AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
CPAP (E0601) may be considered medically necessary for:
• Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than fifteen, or
• Patients in whom polysomnography has documented sleep disordered breathing, with an RDI (respiratory disturbance index) of greater than five and any of the following associated symptoms:
Excessive daytime sleepiness
Impaired cognition
Mood disorders
Insomnia
Documented hypertension
Ischemic heart disease
History of stroke
• Patients who do not have sleep apnea, but who have restrictive lung disease and documented desaturation at night, requiring nocturnal ventilation
• Under individual consideration APAP may be allowed in selective patients in lieu of repeated CPAP titration when the attending sleep center physician indicates that, in his/her opinion the member would be a suitable candidate for this approach based upon member’s knowledge, behavior, and health status.
Diagnosis of OSA with abnormal Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)
1. AHI or RDI =15; Or
2. AHI or RDI between 5 and 14 (requires one)
a. Excessive daytime sleepiness (ESS)
b. Impaired cognition
c. Insomnia
d. Mood disorder
e. Hypertension;
MSLT is considered not medically necessary in the following four situations:
• When performed for routine diagnosis of obstructive sleep apnea; OR
• For routine follow-up after treatment of sleep related disorders; OR
• For evaluation of sleepiness in medical or neurological disorders (other than narcolepsy or idiopathic hypersomnia), including, but not limited to, insomnia,
circadian rhythm disorders, and Shift Work Sleep Disorder (SWSD); OR
• Portable MSLT performed in the home setting.
ICD-10 DiagnosisCode ICD-10 Diagnosis Description
F40.241 Acrophobia
F43.0 Acute stress reaction
F43.22 Adjustment disorder with anxiety
F43.21 Adjustment disorder with depressed mood
F43.24 Adjustment disorder with disturbance of conduct
F43.23 Adjustment disorder with mixed anxiety and depressed mood
F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
F43.29 Adjustment disorder with other symptoms
F43.20 Adjustment disorder, unspecified
F51.01 Primary insomnia
F51.02 Adjustment insomnia
F51.03 Paradoxical insomnia
F51.04 Psychophysiologic insomnia
F51.05 Insomnia due to other mental disorder
F51.09 Other insomnia not due to a substance of known physiological condition
F98.5 Adult onset fluency disorder
F40.01 Agoraphobia with panic disorder
F40.02 Agoraphobia without panic disorder
F40.00 Agoraphobia, unspecified
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.121 Alcohol abuse with intoxication delirium
F10.188 Alcohol abuse with other alcohol-induced disorder
F10.19 Alcohol abuse with unspecified alcohol-induced disorder
F10.280 Alcohol dependence with alcohol-induced anxiety disorder
F10.24 Alcohol dependence with alcohol-induced mood disorder
F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder
F10.27 Alcohol dependence with alcohol-induced persisting dementia
F10.250 Alcohol dependence with alcohol-induced psychotic disorder with delusions
F10.251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations
F10.259 Alcohol dependence with alcohol-induced psychotic disorder, unspecified
F10.281 Alcohol dependence with alcohol-induced sexual dysfunction
F10.282 Alcohol dependence with alcohol-induced sleep disorder
F10.221 Alcohol dependence with intoxication delirium
F10.288 Alcohol dependence with other alcohol-induced disorder
F10.29 Alcohol dependence with unspecified alcohol-induced disorder
F18.951 Inhalant use, unspecified with inhalant-induced psychotic disorder with hallucinations
F18.959 Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified
F18.921 Inhalant use, unspecified with intoxication with delirium
F51.05 Insomnia due to other mental disorder
F51.12 Insufficient sleep syndrome
F63.81 Intermittent explosive disorder
F63.2 Kleptomania
F33.2 Major depressive disorder, recurrent severe without psychotic features
F33.42 Major depressive disorder, recurrent, in full remission
F33.41 Major depressive disorder, recurrent, in partial remission
F33.40 Major depressive disorder, recurrent, in remission, unspecified
F33.0 Major depressive disorder, recurrent, mild
F33.1 Major depressive disorder, recurrent, moderate
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
F33.9 Major depressive disorder, recurrent, unspecified
F32.5 Major depressive disorder, single episode, in full remission
F32.4 Major depressive disorder, single episode, in partial remission
F32.0 Major depressive disorder, single episode, mild
F32.1 Major depressive disorder, single episode, moderate
F32.3 Major depressive disorder, single episode, severe with psychotic features
F32.2 Major depressive disorder, single episode, severe without psychotic features
F32.9 Major depressive disorder, single episode, unspecified
F52.21 Male erectile disorder
F52.32 Male orgasmic disorder
F30.4 Manic episode in full remission
F30.3 Manic episode in partial remission
F30.11 Manic episode without psychotic symptoms, mild
F30.12 Manic episode without psychotic symptoms, moderate
F30.10 Manic episode without psychotic symptoms, unspecified
F30.2 Manic episode, severe with psychotic symptoms
F30.13 Manic episode, severe, without psychotic symptoms
F30.9 Manic episode, unspecified
F42.2 Mixed obsessional thoughts and acts
F06.31 Mood disorder due to known physiological condition with depressive features
F06.32 Mood disorder due to known physiological condition with major depressive-like episode
F06.33 Mood disorder due to known physiological condition with manic features
F06.34 Mood disorder due to known physiological condition with mixed features
F06.30 Mood disorder due to known physiological condition, unspecified
F91.8 Other conduct disorders
F32.8 Other depressive episodes
F80.89 Other developmental disorders of speech and language
F88 Other disorders of psychological development
F50.8 Other eating disorders
F98.29 Other feeding disorders of infancy and early childhood
F64.8 Other gender identity disorders
F45.29 Other hypochondriacal disorders
F63.8 Other impulse disorders
F51.09 Other insomnia not due to a substance or known physiological condition
F42.8 Other obsessive compulsive disorder
F30.8 Other manic episodes
F41.3 Other mixed anxiety disorders
F40.228 Other natural environment type phobia
F65.89 Other paraphilias
F34.8 Other persistent mood Âșaffective» disorders
F07.89 Other personality and behavioral disorders due to known physiological condition
F84.8 Other pervasive developmental disorders
F40.8 Other phobic anxiety disorders
F19.121 Other psychoactive substance abuse with intoxication delirium
F19.122 Other psychoactive substance abuse with intoxication with perceptual disturbances
F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.14 Other psychoactive substance abuse with psychoactive substance-induced mood disorder
F19.16 Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder
F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia
F19.150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delus
F19.151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallu
F19.159 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecifi
F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder
F15.159 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified
F15.181 Other stimulant abuse with stimulant-induced sexual dysfunction
F15.182 Other stimulant abuse with stimulant-induced sleep disorder
F15.19 Other stimulant abuse with unspecified stimulant-induced disorder
F15.221 Other stimulant dependence with intoxication delirium
F15.222 Other stimulant dependence with intoxication with perceptual disturbance
F15.288 Other stimulant dependence with other stimulant-induced disorder
F15.280 Other stimulant dependence with stimulant-induced anxiety disorder
F15.24 Other stimulant dependence with stimulant-induced mood disorder
F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions
F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations
F15.259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified
F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction
F15.282 Other stimulant dependence with stimulant-induced sleep disorder
F15.29 Other stimulant dependence with unspecified stimulant-induced disorder
F15.921 Other stimulant use, unspecified with intoxication delirium
F15.922 Other stimulant use, unspecified with intoxication with perceptual disturbance
F15.988 Other stimulant use, unspecified with other stimulant-induced disorder
F15.980 Other stimulant use, unspecified with stimulant-induced anxiety disorder
F15.94 Other stimulant use, unspecified with stimulant-induced mood disorder
F15.950 Other stimulant use, unspecified with stimulant-induced psychotic disorder with delusions
F15.951 Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations
F15.959 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified
F15.981 Other stimulant use, unspecified with stimulant-induced sexual dysfunction
F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder
F95.8 Other tic disorders
F45.41 Pain disorder exclusively related to psychological factors
F45.42 Pain disorder with related psychological factors
F41.0 Panic disorder Âșepisodic paroxysmal anxiety» without agoraphobia
F51.03 Paradoxical insomnia
F60.0 Paranoid personality disorder
F20.0 Paranoid schizophrenia
F65.9 Paraphilia, unspecified
F63.0 Pathological gambling
F65.4 Pedophilia
F34.9 Persistent mood Âșaffective» disorder, unspecified
F07.0 Personality change due to known physiological condition
F60.9 Personality disorder, unspecified
F84.9 Pervasive developmental disorder, unspecified
F40.9 Phobic anxiety disorder, unspecified
F98.3 Pica of infancy and childhood
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic
F43.10 Post-traumatic stress disorder, unspecified
F07.81 Postconcussional syndrome
F52.4 Premature ejaculation
F32.81 Premenstrual dysphonic disorder
F51.11 Primary hypersomnia
F51.01 Primary insomnia
F48.2 Pseudobulbar affect
F06.2 Psychotic disorder with delusions due to known physiological condition
F06.0 Psychotic disorder with hallucinations due to known physiological condition
F53 Puerperal psychosis
F63.1 Pyromania
F43.9 Reaction to severe stress, unspecified
F94.1 Reactive attachment disorder of childhood
F20.5 Residual schizophrenia
F98.21 Rumination disorder of infancy
F65.50 Sadomasochism, unspecified
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
F25.9 Schizoaffective disorder, unspecified
F60.1 Schizoid personality disorder
F20.9 Schizophrenia, unspecified
F20.81 Schizophreniform disorder
F21 Schizotypal disorder
F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium
F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolyticinduced disorder
F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced anxiety disorde
F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced mood disorder
F13.151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced psychotic disor
Medicare denial codes, reason, remark and adjustment codes.Medicare, UHC, BCBS, Medicaid denial codes and insurance appeal. Sample appeal letter for denial claim. CO, PR and OA denial reason codes codes.
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