Regence BlueShieldAll Plans · Coverage · Medical Policy · ENT (Ear, Nose & Throat), Sleep MedicineMedium impact
Hypoglossal Nerve Stimulation
Effective date
Jan 1, 2027
Identified
Oct 7, 2026
Summary
Effective January 1, 2027, hypoglossal nerve stimulation using the Inspire device may be considered medically necessary in adults with obstructive sleep apnea when the AHI is at least 15 and no more than 100 with less than 25% central apneas, when PAP has failed or the patient is not an appropriate PAP candidate, when BMI is less than 40 kg/m2, when drug-induced sleep endoscopy shows non-concentric retropalatal obstruction, and when the patient is 22 years of age or older, or is 18 to 22 years of age and has had or is contraindicated for adenotonsillectomy. Adolescents and young adults aged 10 to 21 with Down syndrome may be considered under separate criteria, and revisions to an existing stimulator may be considered medically necessary after placement. Replacement of all or part of a stimulator or generator may be considered medically necessary when it is malfunctioning, cannot be repaired, or is no longer under warranty. Hypoglossal nerve stimulation is not medically necessary when the AHI criterion or the PAP-failure criterion is not met, including PAP refusal, and is investigational when criteria are not met for reasons other than PAP failure or intolerance, when used with other devices such as Genio or the aura6000 system, and for all other indications.
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01Effective January 1, 2027: Submit the following documentation for review: history and physical or chart notes; current symptomology; documentation that conservative medical therapies failed; CPAP trial results; documentation that the patient is not an appropriate PAP candidate with clinical rationale, if applicable; sleep study results with the apnea-hypopnea index (AHI) scored under either the AASM or CMS scoring rules; drug-induced sleep endoscopy (DISE) results; and, for a replacement, documentation that the stimulator or generator is malfunctioning, cannot be repaired, or is no longer under warranty.
02If any of these items are not submitted, it could impact the review and decision outcome.
03Replacement is not medically appropriate while the device is in its warranty period or can be repaired or adapted adequately.
04Contract language takes precedence over this medical policy, and some member contracts have specific benefit limitations for orthognathic surgery.
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