Surgical Treatment of Sleep Apnea and Snoring

Policy Number: MA 1.128

Effective Date: 2/1/2026

Policy

Obstructive Sleep Apnea

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty, relocation pharyngoplasty) may be considered medically necessary for the treatment of clinically significant obstructive sleep apnea (OSA) syndrome in appropriately select adults who have failed an adequate trial of continuous positive airway pressure (CPAP) or failed an adequate trial of an oral appliance. Clinically significant OSA is defined as those individuals who have:

• Apnea/Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of 15 or more events per hour, or
• AHI or RDI of at least 5 events per hour with 1 or more signs or symptoms associated with OSA (e.g., excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke).

Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular-maxillary advancement (MMA), may be considered medically necessary in appropriately selected adults with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have failed an adequate trial of CPAP or failed an adequate trial of an oral appliance. Clinically significant OSA is defined as those individuals who have:

• AHI or RDI of 15 or more events per hour, or
• AHI or RDI of at least 5 events per hour with 1 or more signs or symptoms associated with OSA (e.g., excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke).

Adenotonsillectomy may be considered medically necessary for pediatric individuals with clinically significant OSA and hypertrophic tonsils. Clinically significant OSA is defined as those pediatric individuals who have:

• AHI or RDI of at least 5 per hour, or
• AHI or RDI of at least 1.5 per hour in an individual with excessive daytime sleepiness, behavioral problems, or hyperactivity.

Surgical treatment of OSA that does not meet the criteria above would be considered investigational as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. (See policy guidelines)

The following minimally invasive surgical procedures are considered investigational for the sole or adjunctive treatment of OSA or upper airway resistance syndrome as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure:

• AHI or RDI of at least 5 per hour, or
• Laser-assisted palatoplasty or radiofrequency volumetric tissue reduction of the palatal tissues;
• Radiofrequency volumetric tissue reduction of the tongue, with or without radiofrequency reduction of the palatal tissues;
• Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation, injection of a sclerosing agent, and the implantation of palatal implants;
• Tongue base suspension;
• All other minimally invasive surgical procedures not described above.

All interventions, including laser-assisted palatoplasty, radiofrequency volumetric tissue reduction of the palate, or palatal stiffening procedures, are considered investigational for the treatment of snoring in the absence of documented OSA as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure; snoring alone is not considered a medical condition.

Central Sleep Apnea

The use of phrenic nerve stimulation for central sleep apnea is considered investigational in all situations as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure.

Policy Guidelines

For hypoglossal nerve stimulation, see LCD L38385 Hypoglossal Nerve Stimulation for the Treatment of OSA.

Continuous positive airway pressure is the preferred first-line treatment for most patients. A smaller number of patients may use oral appliances as a first-line treatment (see evidence review 2.045). The Apnea/Hypopnea Index is the total number events (apnea or hypopnea) per hour of recorded sleep. The Respiratory Disturbance Index is the total number events (apnea or hypopnea) per hour of recording time. An obstructive apnea is defined as at least a 10-second cessation of respiration associated with ongoing ventilatory effort. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow compared with baseline and with at least a 4% oxygen desaturation.

Drug-induced sleep endoscopy (DISE) replicates sleep with an infusion of propofol. DISE will suggest either a flat, anterior-posterior collapse or complete circumferential oropharyngeal collapse. Concentric collapse decreases the success of hypoglossal nerve stimulation and is an exclusion criteria from the Food and Drug Administration.

Product Variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO – Refer to FEP Medical Policy Manual.

Description/Background

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of upper airway obstruction due to the collapse and obstruction of the upper airway during sleep. The hallmark symptom of OSA is excessive daytime sleepiness, and the typical clinical sign of OSA is snoring, which can abruptly cease and be followed by gasping associated with a brief arousal from sleep. The snoring resumes when the patient falls back to sleep, and the cycle of snoring/apnea/arousal may be repeated as frequently as every minute throughout the night. Sleep fragmentation associated with the repeated arousal during sleep can impair daytime activity. For example, adults with OSA-associated daytime somnolence are thought to be at higher risk for accidents involving motorized vehicles (i.e., cars, trucks, heavy equipment). OSA in children may result in neurocognitive impairment and behavioral problems. In addition, OSA affects the cardiovascular and pulmonary systems. For example, apnea leads to periods of hypoxia, alveolar hypoventilation, hypercapnia, and acidosis. This, in turn, can cause systemic hypertension, cardiac arrhythmias, and cor pulmonale. Systemic hypertension is common in patients with OSA. Severe OSA is associated with decreased survival, presumably related to severe hypoxemia, hypertension, or an increase in automobile accidents related to overwhelming sleepiness.

There are racial and ethnic health disparities seen for OSA, impacting the prevalence of disease and accessibility to treatment options, particularly affecting children. Black children are 4 to 6 times more likely to have OSA than White children. Among young adults 26 years of age or younger, African American individuals are 88% more likely to have OSA compared to White individuals. Another study found that African American individuals 65 years of age and older were 2.1 times more likely to have severe OSA than White individuals of the same age group. These health disparities may affect accessibility to treatment for OSA and impact health outcomes. One analysis of insurance claims data, including over 500,000 patients with a diagnosis of OSA, found that increased age above the 18- to 29- year range (p<.001) and Black race (p=.020) were independently associated with a decreased likelihood of receiving surgery for sleep apnea. Lee et al (2022) found that Black men had a continuous mortality increase specifically related to OSA over the study period (1999 to 2019; annual percentage change 2.7%; 95% confidence interval, 1.2 to 4.2) compared to any other racial group.

Regulatory Status

The regulatory status of minimally invasive surgical interventions is shown in Table 1.

Table 1. Minimally Invasive Surgical Interventions for Obstructive Sleep Apnea

AHI: Apnea/Hypopnea Index; CPAP: continuous positive airway pressure; IDE: investigational device exemption; LAUP: Laser-assisted uvulopalatoplasty; OSA: obstructive sleep apnea.

Central Sleep Apnea

Central sleep apnea (CSA) is characterized by repetitive cessation or decrease in both airflow and ventilatory effort during sleep. Central sleep apnea may be idiopathic or secondary (associated with a medical condition such as congestive heart failure, drugs, or high-altitude breathing). Apneas associated with Cheyne-Stokes respiration are common among patients with heart failure (HF) or who have had strokes, and account for about half of the population with CSA. Central sleep apnea is less common than obstructive sleep apnea. Based on analyses of a large community-based cohort of participants 40 years of age and older in the Sleep Heart Health Study, the estimated prevalence of CSA and obstructive sleep apnea are 0.9% and 47.6%, respectively. Risk factors for CSA include age (>65 years), male gender, history of HF, history of stroke, other medical conditions (acromegaly, renal failure, atrial fibrillation, low cervical tetraplegia, and primary mitochondrial diseases), and opioid use. Individuals with CSA have difficulty maintaining sleep and therefore experience excessive daytime sleepiness, poor concentration, and morning headaches, and are at higher risk for accidents and injuries.

Treatment

The goal of treatment is to normalize sleep-related breathing patterns. Because most cases of CSA are secondary to an underlying condition, central nervous system pathology, or medication side effects, treatment of the underlying condition or removal of the medication may improve CSA. Treatment recommendations differ depending on the classification of CSA as either hyperventilation-related (most common, including primary CSA and those relating to HF or high-altitude breathing) or hypoventilation-related (less common, relating to central nervous system diseases or use of nervous system suppressing drugs such as opioids).

For patients with hyperventilation-related CSA, continuous positive airway pressure (CPAP) is considered first-line therapy. Due to CPAP discomfort, patient compliance may become an issue. Supplemental oxygen during sleep may be considered for patients experiencing hypoxia during sleep or who cannot tolerate CPAP. Patients with CSA due to HF with an ejection fraction >45%, and who are not responding with CPAP and oxygen therapy, may consider bilevel positive airway pressure or adaptive servo-ventilation (ASV) as second-line therapy. Bilevel positive airway pressure devices have 2 pressure settings, 1 for inhalation and 1 for exhalation. Adaptive servo-ventilation uses both inspiratory and expiratory pressure and titrates the pressure to maintain adequate air movement. However, a clinical trial reported increased cardiovascular mortality with ASV in patients with CSA due to HF and with an ejection fraction <45%, and therefore, ASV is not recommended for this group.

For patients with hypoventilation-related CSA, first-line therapy is bilevel positive airway pressure.

Pharmacologic therapy with a respiratory stimulant may be recommended to patients with hyper- or hypoventilation CSA who do not benefit from positive airway pressure devices, though close monitoring is necessary due to the potential for adverse effects such as rapid heart rate, high blood pressure, and panic attacks.

Phrenic Nerve Stimulation

Several phrenic nerve stimulation systems are available for patients who are ventilator dependent. These systems stimulate the phrenic nerve in the chest, which sends signals to the diaphragm to restore a normal breathing pattern. Currently, there is 1 phrenic nerve stimulation device approved by the U.S. Food and Drug Administration (FDA) for CSA, the remedē System (Zoll Medical). A cardiologist implants the battery-powered device under the skin in the right or left pectoral region using local anesthesia. The device has 2 leads, 1 to stimulate a phrenic nerve (either the left pericardiophrenic or right brachiocephalic vein) and 1 to sense breathing. The device runs on an algorithm that activates automatically at night when the patient is in a sleeping position and suspends therapy when the patient sits up. Patient-specific changes in programming can be conducted externally by a programmer.

Regulatory Status

In October 2017, the remedē System (Respicardia, Inc [now Zoll Medical]; Minnetonka, MN) was approved by the FDA through the premarket approval application process (PMA #P160039). The approved indication is for the treatment of moderate to severe CSA in adults. Follow-up will continue for 5 years in the post-approval study. FDA product code: PSR.

Rationale

Summary of Evidence

OSA

For individuals who have OSA who receive laser-assisted uvulopalatoplasty, the evidence includes a single randomized controlled trial (RCT). Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The trial indicates reductions in snoring, but limited efficacy on the Apnea/Hypopnea Index (AHI) or symptoms in patients with mild-to-moderate OSA. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have OSA who receive a radiofrequency volumetric reduction of palatal tissues and base of tongue, the evidence includes 2 sham-controlled randomized trials. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Single-stage radiofrequency to palatal tissues did not improve outcomes compared with sham. Multiple sessions of radiofrequency to the palate and base of tongue did not significantly (statistically or clinically) improve AHI, and the improvement in functional outcomes was not clinically significant. The prospective cohort study included 56 patients with mild-to-moderate OSA who received 3 sessions of office-based multilevel RFA. Results demonstrated improvement in AHI and Oxygen Desaturation Index (ODI) at the 6-month follow up. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have OSA who receive palatal stiffening procedures, the evidence includes two sham-controlled randomized trials. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The 2 RCTs differed in their inclusion criteria, with the study that excluded patients with Friedman tongue position of IV and palate of 3.5 cm or longer reporting greater improvement in AHI (45% success) and snoring (change of -4.7 on a 10-point visual analog scale) than the second trial. Additional studies are needed to corroborate the results of the more successful trial and, if successful, define the appropriate selection criteria. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have OSA who receive tongue base suspension, the evidence includes a feasibility RCT with 17 patients. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The single RCT compared tongue suspension plus UPPP with tongue advancement plus uvulopalatopharyngoplasty (UPPP) and showed success rates of 50% to 57% for both procedures. Additional RCTs with a larger number of subjects are needed to determine whether tongue suspension alone or added to UPPP improves the net health outcome. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

CSA

For individuals with CSA who receive phrenic nerve stimulation, the evidence includes a systematic review, 1 randomized controlled trial (RCT), and observational studies. Relevant outcomes are change in disease status, functional outcomes, and quality of life. The RCT compared the use of phrenic nerve stimulation to no treatment among patients with CSA of various etiologies. All patients received implantation of the phrenic nerve stimulation system, with activation of the system after 1 month in the intervention group and activation after 6 months in the control group. Activation is delayed 1 month after implantation to allow for lead healing. At 6 months follow-up, the patients with the activated device experienced significant improvements in several sleep metrics and quality of life measures. At 12 months follow-up, patients in the activated device arm showed sustained significant improvements from baseline in sleep metrics and quality of life. A subgroup analysis of patients with heart failure combined 6- and 12-month data from patients in the intervention group and 12- and 18-month data from the control group. Results from this subgroup analysis showed significant improvements in sleep metrics and quality of life at 12 months compared with baseline. Results from observational studies supported the results of the RCT. An invasive procedure would typically be considered only if non-surgical treatments had failed, but there is limited data in which phrenic nerve stimulation was evaluated in patients who had failed the current standard of care, positive airway pressure, or respiratory stimulant medication. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

AHI is the average number of apneas or hypopneas per hour of sleep

Apnea in adults is defined as a drop in airflow by ≥90% of the pre-event baseline for at least ten (10) seconds. Due to faster respiratory rates in children, pediatric scoring criteria define apnea as ≥2 missed breaths, regardless of its duration in seconds.

Hypopnea in adults is scored when the peak airflow drops by at least 30% of the pre-event baseline for at least 10 seconds in association with either at least 3% or 4% decrease in arterial oxygen desaturation (depending on the scoring criteria) or arousal. Hypopneas in children are scored by a ≥50% drop in nasal pressure and either a ≥3% decrease in oxygen saturation or associated arousal.

Intra-oral Appliance is a device placed in the mouth to correct or alleviate malocclusion.

Palatopharyngoplasty refers to a surgical procedure that opens the airway by removing or reshaping tissue in the throat.

RDI is the number of apneas, hypopneas, or respiratory event-related arousals per hour of sleep time. RDI is often used synonymously with the AHI.

REI is the respiratory event index which is the number of events per hour of monitoring time. Used as an alternative to AHI or RDI in-home sleep studies when actual sleep time from EEG is not available.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as required by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding Information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. The codes need to be in numerical order.

Investigational; therefore, not covered: Surgical Treatments for OSA

Investigational; therefore, not covered: Phrenic Nerve Stimulation for Central Sleep Apnea

Covered when medically necessary: Surgical Treatments for OSA

References

OSA

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2. Cohen SM, Howard JJM, Jin MC, et al. Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea. OTO Open. 2022; 6(1): 2473974X221088870. PMID 35321423
3. Lee YC, Chang KY, Mador MJ. Racial disparity in sleep apnea-related mortality in the United States. Sleep Med. Feb 2022; 90: 204-213. PMID 35202926
4. Friedman M, Schalch P, Lin HC, et al. Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. Feb 2008; 138(2): 209-16. PMID 18241718
5. Lee LA, Yu JF, Lo YL, et al. Comparative effects of snoring sound between two minimally invasive surgeries in the treatment of snoring: a randomized controlled trial. PLoS One. 2014; 9(5): e97186. PMID 24816691
6. Patel S, Kon SSC, Nolan CM, et al. The Epworth Sleepiness Scale: Minimum Clinically Important Difference in Obstructive Sleep Apnea. Am J Respir Crit Care Med. Apr 01 2018; 197(7): 961-963. PMID 28961021
7. Ferguson KA, Heighway K, Ruby RR. A randomized trial of laser-assisted uvulopalatoplasty in the treatment of mild obstructive sleep apnea. Am J Respir Crit Care Med. Jan 01 2003; 167(1): 15-9. PMID 12502473
8. Bäck LJ, Liukko T, Rantanen I, et al. Radiofrequency surgery of the soft palate in the treatment of mild obstructive sleep apnea is not effective as a single-stage procedure: A randomized single-blinded placebo-controlled trial. Laryngoscope. Aug 2009; 119(8): 1621-7. PMID 19504550
9. Woodson BT, Steward DL, Weaver EM, et al. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. Jun 2003; 128(6): 848-61. PMID 12825037
10. Herman H, Stern J, Alessi DM, et al. Office-Based Multilevel Radiofrequency Ablation for Mild-to-Moderate Obstructive Sleep Apnea. OTO Open. 2023; 7(1): e19. PMID 36998558
11. Steward DL, Huntley TC, Woodson BT, et al. Palate implants for obstructive sleep apnea: multi-institution, randomized, placebo-controlled study. Otolaryngol Head Neck Surg. Oct 2008; 139(4): 506-10. PMID 18922335
12. Neruntarat C. Long-term results of palatal implants for obstructive sleep apnea. Eur Arch Otorhinolaryngol. Jul 2011; 268(7): 1077-80. PMID 21298386
13. Maurer JT, Sommer JU, Hein G, et al. Palatal implants in the treatment of obstructive sleep apnea: a randomised, placebo-controlled single-centre trial. Eur Arch Otorhinolaryngol. Jul 2012; 269(7): 1851-6. PMID 22228439
14. Thomas AJ, Chavoya M, Terris DJ. Preliminary findings from a prospective, randomized trial of two tongue-base surgeries for sleep-disordered breathing. Otolaryngol Head Neck Surg. Nov 2003; 129(5): 539-46. PMID 14595277
15. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. Dec 01 2021; 17(12): 2499-2505. PMID 34351848
16. Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. Oct 2010; 33(10): 1408-13. PMID 21061864
17. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. Dec 01 2021; 17(12): 2507-2531. PMID 34351849
18. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. Sep 2012; 130(3): e714-55. PMID 22926176
19. American Academy of Otolaryngology -- Head and Neck Surgery. Position Statement: Surgical Management of Obstructive Sleep Apnea. 2021; https://www.entnet.org/resource/position-statement-surgical-management-of-obstructive-sleep-apnea/. Accessed April 14, 2025.
20. Clinical Issues Committee, American Society for Metabolic & Bariatric Surgery. Peri-operative management of obstructive sleep apnea. 2012; https://asmbs.org/resources/peri-operative-management-of-obstructive-sleep- apnea. Accessed April 14, 2025.
21. de Raaff CAL, Gorter-Stam MAW, de Vries N, et al. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis. Jul 2017; 13(7): 1095-1109. PMID 28666588
22. Centers for Medicare & Medicaid Services. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N). 2008; hhttps://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=226&ncdver=3&keyword=osa&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD&contractOption=all&sortBy=relevance&bc=1. Accessed April 14, 2025.

CSA

1. Donovan LM, Kapur VK. Prevalence and Characteristics of Central Compared to Obstructive Sleep Apnea: Analyses from the Sleep Heart Health Study Cohort. Sleep. Jul 01 2016; 39(7): 1353-9. PMID 27166235
2. Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure. N Engl J Med. Sep 17 2015; 373(12): 1095-105. PMID 26323938
3. Wang Y, Huang Y, Xia M, et al. Effect of phrenic nerve stimulation on patients with central sleep apnea: A meta-analysis. Sleep Med Rev. Aug 2023; 70: 101819. PMID 37467524
4. Costanzo MR, Javaheri S, Ponikowski P, et al. Transvenous Phrenic Nerve Stimulation for Treatment of Central Sleep Apnea: Five-Year Safety and Efficacy Outcomes. Nat Sci Sleep. 2021; 13: 515-526. PMID 33953626
5. Oldenburg O, Costanzo MR, Germany R, et al. Improving Nocturnal Hypoxemic Burden with Transvenous Phrenic Nerve Stimulation for the Treatment of Central Sleep Apnea. J Cardiovasc Transl Res. Apr 2021; 14(2): 377-385. PMID 32789619
6. Costanzo MR, Goldberg LR, Ponikowski P, Augostini R, Stellbrink C, Abraham W. Phrenic nerve simulation for central sleep apnea is effective and safe in the presence of concomitant cardiac devices. J Card Fail; Aug 2018; 24(8):S17-8.
7. Zhang X, Ding N, Ni B, et al. Safety and feasibility of chronic transvenous phrenic nerve stimulation for treatment of central sleep apnea in heart failure patients. Clin Respir J. Mar 2017; 11(2): 176-184. PMID 26072733
8. Fox H, Bitter T, Horstkotte D, et al. Long-Term Experience with First-Generation Implantable Neurostimulation Device in Central Sleep Apnea Treatment. Pacing Clin Electrophysiol. May 2017; 40(5): 498-503. PMID 28211952
9. Jagielski D, Ponikowski P, Augostini R, et al. Transvenous stimulation of the phrenic nerve for the treatment of central sleep apnoea: 12 months' experience with the remedē^® System. Eur J Heart Fail. Nov 2016; 18(11): 1386-1393. PMID 27373452
10. Costanzo MR, Ponikowski P, Javaheri S, et al. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial. Lancet. Sep 03 2016; 388(10048): 974-82. PMID 27598679
11. Abraham WT, Jagielski D, Oldenburg O, et al. Phrenic nerve stimulation for the treatment of central sleep apnea. JACC Heart Fail. May 2015; 3(5): 360-369. PMID 25770408
12. Ponikowski P, Javaheri S, Michalkiewicz D, et al. Transvenous phrenic nerve stimulation for the treatment of central sleep apnoea in heart failure. Eur Heart J. Apr 2012; 33(7): 889-94. PMID 21856678
13. Zhang XL, Ding N, Wang H, et al. Transvenous phrenic nerve stimulation in patients with Cheyne-Stokes respiration and congestive heart failure: a safety and proof-of-concept study. Chest. Oct 2012; 142(4): 927-934. PMID 22302299
14. Costanzo MR, Augostini R, Goldberg LR, et al. Design of the remedē System Pivotal Trial: A Prospective, Randomized Study in the Use of Respiratory Rhythm Management to Treat Central Sleep Apnea. J Card Fail. Nov 2015; 21(11): 892-902. PMID 26432647
15. Costanzo MR, Ponikowski P, Javaheri S, et al. Sustained 12 Month Benefit of Phrenic Nerve Stimulation for Central Sleep Apnea. Am J Cardiol. Jun 01 2018; 121(11): 1400-1408. PMID 29735217
16. Fox H, Oldenburg O, Javaheri S, et al. Long-term efficacy and safety of phrenic nerve stimulation for the treatment of central sleep apnea. Sleep. Oct 21 2019; 42(11). PMID 31634407
17. Baumert M, Immanuel S, McKane S, et al. Transvenous phrenic nerve stimulation for the treatment of central sleep apnea reduces episodic hypoxemic burden. Int J Cardiol. May 01 2023; 378: 89-95. PMID 36841294
18. Baumert M, Linz D, McKane S, et al. Transvenous phrenic nerve stimulation is associated with normalization of nocturnal heart rate perturbations in patients with central sleep apnea. Sleep. Sep 08 2023; 46(9). PMID 37284759
19. Hartmann S, Immanuel S, McKane S, et al. Transvenous phrenic nerve stimulation for treating central sleep apnea may regulate sleep microstructure. Sleep Med. Jan 2024; 113: 70-75. PMID 37988861
20. Samii S, McKane S, Meyer TE, et al. Analysis by sex of safety and effectiveness of transvenous phrenic nerve stimulation. Sleep Breath. Mar 2024; 28(1): 165-171. PMID 37436669
21. Abraham WT, Oldenburg O, Lainscak M, et al. Win ratio analysis of transvenous phrenic nerve stimulation to treat central sleep apnoea in heart failure. ESC Heart Fail. Feb 2025; 12(1): 80-86. PMID 39422417
22. Costanzo MR, Ponikowski P, Coats A, et al. Phrenic nerve stimulation to treat patients with central sleep apnoea and heart failure. Eur J Heart Fail. Dec 2018; 20(12): 1746-1754. PMID 30303611
23. Hill L, Meyer T, McKane S, et al. Transvenous phrenic nerve stimulation to treat central sleep apnoea in patients with heart failure may improve sleep, quality of life, and symptoms. Eur J Cardiovasc Nurs. Jul 19 2023; 22(5): 489-497. PMID 36125322
24. Wang Y, Schoebel J, Han J, et al. Phrenic nerve stimulation for the treatment of central sleep apnea in patients with heart failure. Sleep Breath. Jun 2023; 27(3): 1027-1032. PMID 35978055
25. Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. Jan 01 2012; 35(1): 17-40. PMID 22215916
26. Aurora RN, Bista SR, Casey KR, et al. Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline: "The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based Literature Review and Meta-Analyses". J Clin Sleep Med. May 15 2016; 12(5): 757-61. PMID 27092695
27. Abraham WT, Oldenburg O, Lainscak M, et al. Win ratio analysis of transvenous phrenic nerve stimulation to treat central sleep apnoea in heart failure. ESC Heart Fail. Feb 2025; 12(1): 80-86. PMID 39422417

Policy History

• MA 1.128
• 10/17/2025 Partial commercial adoption. Removed hypoglossal stimulation statements and procedure codes.