REVIEW REQUEST FOR
Oral, Pharyngeal and Maxillofacial Surgical
Treatment for Obstructive Sleep Apnea
Provider Data Collection Tool Based on Coverage Guideline SURG.00129
Policy Last Review Date: 11/13/2014
Policy Effective Date:
01/13/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number/HCID:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
01/13/2015
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Date/Date Range of Service:
Service Requested (CPT/HCPCS if known):
Office Fax Number:
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please complete the following portion before proceeding to the specific request
Individual has the following documented condition(s): (Check all that apply)
Hypertension
Cardiac arrhythmias
Pulmonary hypertension
Documented ischemic heart disease
Impaired cognition or mood disorders
Ischemic heart disease
History of stroke
Pulmonary hypertension
Excessive daytime sleepiness as documented by a score greater than 10 on the Epworth Sleepiness scale
Excessive daytime sleepiness as documented by inappropriate daytime napping ( for example,, during driving,
conversation or eating) or sleepiness that interferes with daily activities
Individual failed or did not tolerate CPAP as defined by documentation of the following criteria in the medical record
(check all that apply):
Claustrophobia
Inability to breathe through the nose
Pain or discomfort
Individual intolerance
High pressures of CPAP (>10 cm H2O) - complaining of pressure discomfort
Other:
Individual is 18 years of age or older or there is documentation that skeletal growth is complete based on long bone x-ray
or serial cephalometrics showing no change in facial bone relationships for at least the last three consecutive months
Request is to treat snoring without diagnosed obstructive sleep apnea
Uvulopalatopharyngoplasty (UPPP)
Request is for Uvulopalatopharyngoplasty (UPPP) as the sole procedure for documented obstructive sleep apnea (OSA
(Check all that apply)
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) greater than 15 events per hour and less
than 40 events per hour
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) between 10-15 events per hour
Fiberoptic endoscopy suggests retro-palatal narrowing is the primary source of airway obstruction
Other:
Request is for UPPP as part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction
(for example, genioglossal advancement, hyoid myotomy and suspension): (Check all that apply)
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) greater than 15 events per hour
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) between 10-15 events per hour
Fiberoptic endoscopy suggests retro-palatal narrowing is a contributing source of airway obstruction
Other:
Request is for UPPP to treat UARS (upper airway resistance syndrome)
Soft Tissue Reconstruction
Request is for hyoid myotomy and suspension, with or without mandibular osteotomy with genioglossus (tongue)
advancement for the treatment of obstructive sleep apnea: (Check all that apply)
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) greater than 15 events per hour
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) is greater than or equal to 5 events per
hour and less than 15 events per hour
There is significant soft tissue and/or tongue base abnormalities with airway collapse. (Objective evidence
of hypopharyngeal obstruction may be documented by either fiberoptic endoscopy or cephalometric radiographs)
Other:
Jaw Realignment Surgery
Request is for jaw realignment surgery (i.e., maxillomandibular advancement) for the treatment of obstructive sleep apnea:
(Check all that apply)
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) greater than 15 events per hour
Apnea Hypopnea Index (AHI)** or Respiratory Disturbance Index (RDI) is greater than or equal to 5 events per
hour and less than 15 events per hour
Individual has failed surgical intervention with either UPPP or genioglossus advancement and/or hyoid myotomy
with suspension or both of these surgical procedures
Individual with a documented severe jaw/facial bony abnormality that contributes to OSA, including, but not
limited to, craniofacial abnormalities, micrognathia, retrognathia, or small retro-positioned jaw with associated
overbite and small mouth
Other:
Other Surgical Requests
Request is for palatal implants to treat OSA
Request is for Cautery-assisted Palatal Stiffening (CAPSO) to treat OSA
Request is for Laser-Assisted Uvulopalatoplasty (LAUP) to treat OSA
Request is for Radiofrequency Volumetric Tissue Reduction (RFVTR) of the soft palate and/or the base of the tongue
including Somnoplasty® and Coblation® to treat OSA
Request is for nasal surgery to treat OSA
Request is for transpalatal advancement pharyngoplasty to treat OSA
Request is for bone-anchored tongue base suspension systems by permanent suture
techniques (which include AIRvanceTM System and the ENCORETM Tongue Suspension System).
Request is for hypoglossal nerve stimulation (Inspire® Upper Airway Stimulation system).
Other:
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**Note: The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a
minimum of two hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e., the AHI may not be
extrapolated or projected)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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