DESCRIPTION
Uvulopalatopharyngoplasty (UPPP) and palatopharyngoplasty (PPP) are surgical procedures that attempt to create a permanent, non-collapsing oropharyngeal airway. These include several technical variations. All include the basic UPPP procedure, but additional surgery is often performed, such as tonsillectomy or septoplasty. This procedure would be used to correct obstructive sleep apnea syndrome. This syndrome is characterized by repetitive episodes of upper airway obstruction that occur during sleep, usually associated with a reduction in blood oxygen saturation. The procedure is also used to treat upper airway resistance syndrome. This syndrome presents with a normal apnea hypopnea index (AHI) and fragmented sleep related to airway resistance.
POLICY
Uvulopalatopharyngoplasty / palatopharyngoplasty for the treatment of sleep disorders are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Uvulopalatopharyngoplasty / palatopharyngoplasty for socially disruptive snoring alone are considered not medically necessary.
See also:
MEDICAL APPROPRIATENESS
Uvulopalatopharyngoplasty / palatopharyngoplasty are considered medically appropriate in selected individuals if ALL of the following criteria are met:
ANY ONE of the following:
Clinically significant obstructive sleep apnea syndrome (OSA)
Upper airway resistance syndrome (UARS) due to ANY ONE of the following:
type I obstruction (oropharynx)
type II obstruction (oropharynx/hypopharynx)
Not responsive to or does not tolerate nasal continuous positive airway pressure (CPAP)
Full polysomnogram rules out non-obstructive causes of sleep apnea
Presurgical physical evaluation supports the need for UPPP/ PPP
Fiberoptic pharyngoscopy or cephalometric radiographs with tracing confirmed the site of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue])
ADDITIONAL INFORMATION
Appropriate selection of individuals for the surgical treatment of obstructive sleep apnea involves the identification of individuals with clinically significant obstructive disorders. Individuals with an apnea-hypopnea index (AHI) greater than 20 are at greater risk of mortality associated with this degree of obstruction. Milder forms of obstruction with an AHI index between five (considered normal) and 20 are considered clinically significant only if associated with a significant history of daytime sleepiness or hypertension.
Upper airway resistance syndrome, characterized by a normal AHI but with sleep fragmentation related to subtle airway resistance, is considered clinically significant only if there are more than 10 episodes of EEG arousal per hour of sleep in association with negative intrathoracic pressures. In addition, the individual must also have a documented history of excessive daytime sleepiness.
Levels of oxygen desaturation are not used a criterion for surgical treatment as there is no accepted definition of a clinically significant level of oxygen desaturation, and the level of desaturation may depend on other co-morbidities (e.g., COPD) not related to OSA. In addition, a reduction in the O2 saturation occurs as a result of airway obstruction, as measured by the AHI.
Published literature supports the following: In phase 1 surgery, individuals with type I obstruction (soft palate) should receive uvulopalatopharyngoplasty (UPPP), individuals with type II obstruction (palate and base of tongue) should receive UPPP and mandibular osteotomy/genioglossus advancement with hyoid myotomy/suspension (GAHM) at the same setting, and individuals with type III obstruction (base of tongue) receive GAHM. Follow-up polysomnograms should be obtained at 6 months and unsuccessful phase 1 surgeries are offered phase 2 reconstruction, maxillary and mandibular advancement osteotomy (MMO).
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2005). Surgical management of obstructive sleep apnea syndrome/upper airway resistance syndrome (7.01.51). Retrieved July 7, 2009 from BlueWeb.
Bolden, N., Smith, C., & Auckley, D. (2007). Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol. Journal of Clinical Anesthesia, 21 (4), 286 - 293. (Level 5 Evidence)
Goode, R. (2007).Success and Failure in Treatment of Sleep Apnea Patients. Otolaryngologic Clinics of North America, 40 (4), 891 - 901. (Level 5 Evidence)
Gross, J. Bachenberg, K., Benumof, J., Caplan, R., Connis, R., Cote, J., et al. (2006). Practice Guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology, 104 (5), 1081 - 1093. (Level 5 Evidence)
Hayes. Medical Technology Directory. (2005, September). Sleep apnea treatment, surgical. Retrieved July 7, 2009 from www.Hayesinc.com/subscribers. (77 articles and/or guidelines reviewed)
National Guideline Clearinghouse. (2006, March). Guideline: Diagnosis and treatment of obstructive sleep apnea in adults. Retrieved July 15, 2009, from http://www.guideline.gov/summary/summary.aspx?doc_id=12694&nbr=006582&string=uvulopalatopharyngoplasty.
Norman, D., & Loredo, J. (2008). Obstructive sleep apnea in older adults. Clinics in Geriatric Medicine, 24 (1), 151 - 165. (Level 5 Evidence)
Sundaram, S., Lim, J., Lasserson. T., Surgery for obstructive sleep apnoea in adults. Cochrane Database of systemic reviews 2005, Issue 4 Art. No.: CD0010014. DOI: 10. 1002/14651858.CD001004.pub2.
The National Institute for Health and Clinical Excellence. Interventional procedure guidance 124. (2005, May). Radiofrequency ablation of the soft palate for snoring. Retrieved July 7, 2009 from http://www.nice.org.uk/nicemedia/pdf/ip/IPG124guidance.pdf.
U.S. Food and Drug Administration. (2004, September). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K041285. Retrieved July7, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf4/K041285.pdf.
ORIGINAL EFFECTIVE DATE: 3/1985
MOST RECENT REVIEW DATE: 8/13/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.