Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Published 02/17/2022

The hypoglossal nerve stimulator (HSN) is an implanted medical device that reduces the occurrence of Obstructive Sleep Apnea (OSA) by electrically stimulating the hypoglossal nerve, which causes tongue movement. This stimulation is timed with breathing to relieve upper airway obstruction. The hypoglossal nerve stimulation system is fully implanted beneath the skin and controlled with a remote, allowing patients to sleep free from devices on the face or in the mouth. Hypoglossal nerve stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea (OSA) when criteria is met.

Meeting Medical Necessity

  • Beneficiary is 22 years of age or older
  • Body mass index (BMI) is less than 35 kg/m2
  • A polysomnography (PSG) demonstrating an AHI of 15 to 65 events per hour within 24 months of initial consultation for HNS implant
  • Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25 percent of the total AHI)
  • Shared Decision-Making (SDM) between the beneficiary, sleep physician and qualified otolaryngologist

Refer to the Hypoglossal Nerve Stimulator Checklist (PDF) for remaining criteria.

HNS is not reasonable or necessary when any one of the following contraindications are present:

  • Beneficiaries with central and mixed apneas that make up more than one-quarter of the total AHI
  • BMI 35 kg/m2 or greater
  • Neuromuscular disease
  • Hypoglossal-nerve palsy
  • Severe restrictive or obstructive pulmonary disease
  • Moderate-to-severe pulmonary arterial hypertension
  • Severe valvular heart disease
  • New York Heart Association class III or IV heart failure
  • Recent myocardial infarction or severe cardiac arrhythmias (within the past 6 months)
  • Persistent uncontrolled hypertension despite medication use
  • Acute psychiatric disease
  • Coexisting non-respiratory sleep disorders that would confound functional sleep assessment
  • Beneficiaries who are or plan to become pregnant
  • Beneficiaries who are unable or do not have the necessary assistance to operate the device's external programmer
  • Beneficiaries with any condition or procedure that has compromised neurological control of the upper airway
  • HNS implant devices that are not compatible with magnetic resonance imaging (MRI)

Resource: LCD - Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38276).

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