BlueCross BlueShield of Tennessee Medical Policy Manual

Implantable Hypoglossal Nerve Stimulation

DESCRIPTION

Hypoglossal nerve stimulation is proposed as a treatment for obstructive sleep apnea in individuals who are unable to use CPAP. Stimulation of the hypoglossal nerve contracts the genioglossus muscle causing tongue protrusion and stiffening of the anterior pharyngeal wall, potentially decreasing apneic events. Implantable hypoglossal nerve stimulation systems, such as the Inspire® II Upper Airway Stimulation System, include respiratory sensing leads that permit intermittent stimulation during inspiration. Stimulation parameters are titrated during an in-laboratory polysomnography and can be adjusted by the patient during home use. The device is turned on only during sleep periods.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

The role of hypoglossal nerve stimulation among the surgical procedures for obstructive sleep apnea is uncertain. Randomized controlled trials comparing hypoglossal nerve stimulation to conventional surgical procedures are necessary to evaluate benefits and harms. The evidence is insufficient to determine the effects of the technology on health outcomes.

SOURCES

American Academy of Otolaryngology – Head and Neck Surgery. (2016). Position statement: hypoglossal nerve stimulation for treatment of obstructive sleep apnea (OSA). Retrieved July 10, 2017 from  http://www.entnet.org/content/position-statement-hypoglossal-nerve-stimulation-treatment-obstructive-sleep-apnea-osa.

American Academy of Sleep Medicine. (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Retrieved July 10, 2017 from http://www.aasmnet.org/Resources/clinicalguidelines/OSA_Adults.pdf.

Aurora, R., Casey, K., Kristo, D., Auerbach, S., Bista, S., Chowdhuri, S., et al. (2010). Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep, 33 (10), 1408-1413. (Level 2 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2016). Surgical treatment of snoring and obstructive sleep apnea. Retrieved July 10, 2017 from BlueWeb. (31 articles and/or guidelines reviewed)

Certal, V., Zaghi, S., Riaz, M., Vieira, A., Pinheiro, C., Kushida, C, et al. (2015). Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope, 125 (5), 1254-1264. Abstract retrieved July 10, 2017 from PubMed database.

Gillespie, M., Soose, R., Woodson, B., Strohl, K., Maurer, J., de Vries, N., et al. (2017). Upper airway stimulation for obstructive sleep apnea: patient-reported outcomes after 48 months of follow-up. Otolaryngology - Head Neck Surgery, 156 (4), 7658-771. Abstract retrieved July 14, 2017 from PubMed database.

Soose, R., Woodson, B., Gillespie, M., Maurer, J., de Vries, N., Steward, D., (2016). Upper airway stimulation for obstructive sleep apnea: self-reported outcomes at 24 months. Journal of Clinical Sleep Medicine, 12 (1), 43-48. (Level 3 evidence)

Steffen, A., Sommer, J., Hofauer, B., Maurer, J., Hasselbacher, K., & Heiser, C. (2017). Outcome after one year of upper airway stimulation for obstructive sleep apnea in a multicenter German post-market study. The Laryngoscope, 2017 May 31. Doi: 10.1002/lary.26688. [Epub ahead of print]. (Level 4 evidence)

Strollo, P., Gillespie, M., Soose, R., Maurer, J., de Vries, N., Cornelius, J., et al. (2015). Upper airway stimulation for obstructive sleep apnea: durability of the treatment effect at 18 months. Sleep, 38 (10), 1593-1598C. (Level 3 evidence)

Strollo, P., Soose, R., Maurer, J., de Vries, N., Cornelius, J., Froymovich, O., et al. (2014). Upper-airway stimulation for obstructive sleep apnea. The New England Journal of Medicine, 370, 139-149. (Level 3 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, March; last update search March 2017). Hypoglossal nerve stimulation for the treatment of obstructive sleep apnea. Retrieved July 10, 2017 from www.Hayesinc.com/subscribers. (56 articles and/or guidelines reviewed)

Woodson, B., Soose, R., Gillespie, M., Strohl, K., Maurer, J., de Vries, N., et al. (2016). Three-year outcomes of cranial nerve stimulation for obstructive sleep apnea: the STAR trial. Otolaryngology - Head and Neck Surgery, 154 (1), 181-188. (Level 3 evidence)

ORIGINAL EFFECTIVE DATE:  12/1/2017

MOST RECENT REVIEW DATE:  12/1/2017

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.

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