Medical Policy

This document addresses surgical treatments for obstructive sleep apnea (OSA), such as uvulopalatopharyngoplasty (UPPP), hyoid myotomy and jaw realignment surgery, laser surgery, radiofrequency ablation, palatal implants,  and other procedures. This document does not address tonsillectomy, adenoidectomy or nasal surgery.

Note: For information related to hypoglossal nerve stimulation (HNS), please refer to the applicable guidelines used by the plan.

Note: For information related to other technologies utilized in the diagnosis and management of sleep-related disorders, please see:

• CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• CG-MED-105 Selected Sleep Testing Services
• CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
• CG-SURG-36 Adenoidectomy

Medically Necessary:

Uvulopalatopharyngoplasty (UPPP):

Uvulopalatopharyngoplasty (UPPP) is considered medically necessary when all of the following criteria (A-D below) are met:

1. Documented OSA with apnea hypopnea index (AHI) or respiratory disturbance index (RDI) meeting any of the following:
   1. UPPP as sole procedure with AHI (or RDI) greater than 15 events per hour and less than 40 events per hour,
      or
   2. UPPP as sole procedure with AHI (or RDI) between 10-15 events per hour and one or more of the conditions listed below:
      1. Hypertension; or
      2. Cardiac arrhythmias predominately during sleep; or
      3. Pulmonary hypertension; or
      4. Documented ischemic heart disease; or
      5. Impaired cognition or mood disorders; or
      6. History of stroke; or
      7. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness Scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities.
         or
   3. UPPP as part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction, (for example, genioglossal advancement, hyoid myotomy and suspension) with AHI (or RDI) greater than 15 events per hour,
      or
   4. UPPP as part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction, (for example, genioglossal advancement, hyoid myotomy and suspension) with AHI (or RDI) between 10-15 events per hour and one or more of the conditions listed below:
      1. Hypertension; or
      2. Cardiac arrhythmias predominately during sleep; or
      3. Pulmonary hypertension; or
      4. Documented ischemic heart disease; or
      5. Impaired cognition or mood disorders; or
      6. History of stroke; or
      7. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness Scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities.
         and
2. Have failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period;
      and
3. Fiberoptic endoscopy suggests retro-palatal narrowing is the primary source of airway obstruction if UPPP is the sole procedure or a contributing source of airway obstruction if part of a planned staged or combined surgery aimed at also relieving retrolingual obstruction;
   and
4. The 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 3 consecutive months.

Soft Tissue Reconstruction:

Hyoid myotomy and suspension, with or without mandibular osteotomy with genioglossus (tongue) advancement, for the treatment of OSA is considered medically necessary when all of the following criteria (A-D below) are met:

1. The treatment of OSA in the individual is medically necessary based on either 1) or 2) below:
   1. AHI or RDI greater than or equal to 15 events per hour;
      or
   2. AHI (or RDI) greater than or equal to 5 events per hour, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
      1. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities; or
      2. Impaired cognition or mood disorders; or
      3. Hypertension; or
      4. Ischemic heart disease or history of stroke; or
      5. Cardiac arrhythmias, or
      6. Pulmonary hypertension.
         and
2. The individual has failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period;
      and
3. There are 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.
   and
4. The 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 3 consecutive months.

Jaw Realignment Surgery:

Jaw realignment surgery (that is, maxillomandibular advancement) is considered medically necessary when all of the following criteria (A-D below) are met:

1. The treatment of OSA in the individual is medically necessary based on either 1) or 2) below:
   1. AHI or RDI greater than or equal to 15 events per hour;
      or
   2. AHI (or RDI) greater than or equal to 5 events per hour, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
      1. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities; or
      2. Impaired cognition or mood disorders; or
      3. Hypertension; or
      4. Ischemic heart disease or history of stroke; or
      5. Cardiac arrhythmias, or
      6. Pulmonary hypertension.
         and
2. The individual has failed treatment with CPAP as demonstrated by either of the following (1 or 2):
   1. An AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights; or
   2. Inability to tolerate CPAP despite adjustments over at least a 1 month period;
      and
3. The individual has failed surgical intervention with any of the following:
   1. UPPP; or
   2. Genioglossus advancement and/or hyoid myotomy with suspension; or
   3. Both of these surgical procedures.
      and
4. The 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 3 consecutive months.

Jaw realignment surgery is also considered medically necessary for individuals 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.

Note: Individuals undergoing jaw realignment surgery may also undergo orthodontic therapy. Orthodontic therapy (that is, placement of orthodontic brackets and wires) may not be a covered benefit under all member benefit plans.

Not Medically Necessary:

UPPP, soft tissue reconstruction or jaw realignment surgery are considered not medically necessary when the criteria above are not met.

The surgical treatment of snoring without OSA is considered not medically necessary in all cases.

Investigational and Not Medically Necessary:

Other surgical treatments for OSA are considered investigational and not medically necessary.

Summary

OSA, a condition where the airway becomes blocked during sleep, may be treated with a range of surgical and non-surgical options. These include procedures to remove or tighten tissues in the throat, reposition bones or apply air pressure through a mask. Each treatment has advantages and disadvantages, and not all have been studied to determine efficacy and safety. Many of the surgeries are used only when standard therapies, like positive airway pressure, fail or are not tolerated.

Surgical treatments such as UPPP, soft tissue reconstruction and jaw realignment surgery may be used to treat OSA when non-surgical treatments such as positive airway pressure have failed. UPPP removes excess tissue in the throat to improve airflow and can reduce apnea severity in the short term, but it is less effective for severe cases and be less effective over time. Soft tissue reconstruction, including hyoid myotomy and genioglossus advancement, can relieve obstruction caused by specific anatomical issues and is often used in combination with UPPP. Jaw realignment surgery (also called maxillomandibular advancement) moves the upper and lower jaws forward to open the airway and is particularly effective in people who have not responded to other treatments; this surgery often requires orthodontic work, can change facial appearance, and has shown success rates of about 80% in studies.

Radiofrequency volumetric tissue reduction (RFVTR) and laser-assisted uvulopalatoplasty (LAUP) aim to reduce tissue volume in the airway, but studies show no significant benefit for apnea reduction, and LAUP may worsen the condition. Cautery-assisted palatal stiffening operation (CAPSO) has shown modest reductions in apnea severity, especially when combined with other procedures, but long-term benefit and comparative effectiveness are unclear. Tongue suspension systems like ENCORE and AIRvance attempt to pull the tongue forward using a bone anchor, but they lack long-term data and have not been studied in large trials. Pillar palatal implants involve inserting small rods into the soft palate to stiffen it, but studies show limited effectiveness and significant design flaws such as small sample sizes and lack of follow-up. TAP/TPAP pulls the soft palate forward to expand the airway and may be more effective than UPPP in some cases, but existing studies are few and evaluation is needed. Cryolysis (Cryosa system) uses cooling to destroy airway tissue and is currently under investigation in clinical trials with no published results to date.

Discussion

General Considerations

In 2009, the American Academy of Sleep Medicine ([AASM], Epstein, 2009), formerly known as the American Sleep Disorders Association, released the clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. This guideline addressed several surgical treatments of OSA, including the following:

• Individuals with severe OSA should have an initial trial of nasal CPAP because greater effectiveness has been shown with this intervention than with the use of oral appliances (OAs).
• Evaluation for primary surgical treatment can be considered in persons with mild OSA who have severe obstructing anatomy that is surgically correctible, (for example, tonsillar hypertrophy obstructing the pharyngeal airway).
• Although the specifics of sleep apnea surgeries are beyond the scope of this guideline, surgical procedures may be considered as a secondary treatment for OSA when the outcome of positive airway pressure (PAP) therapy is inadequate, such as when the individual is intolerant of PAP, or PAP therapy is unable to eliminate OSA.
• Surgery may also be considered as an adjunct therapy when obstructive anatomy or functional deficiencies compromise other therapies or to improve tolerance of other OSA treatments.
• Maxillary and mandibular advancement (MMA) can improve polysomnography (PSG) parameters comparable to CPAP in the majority of individuals.
• Most other sleep apnea surgeries are rarely curative for OSA but may improve clinical outcomes, (e.g., mortality, cardiovascular risk, motor vehicle accidents, function, quality of life (QOL), and symptoms).
• Laser-assisted uvulopalatoplasty (LAUP) is not recommended for the treatment of obstructive sleep apnea .

In 2010, the AASM published practice parameters for surgical modifications of the upper airway for OSA in Adults (Aurora, 2010), which were based on a systematic review and meta-analysis of the evidence currently available (Caples, 2010). Authors of the systematic review/meta-analysis reported that the bulk of the published literature consisted of case series, with a few controlled trials. The studies were characterized by considerable heterogeneity, including varying approaches to pre-operative evaluation and postoperative follow-up. Using the change in AHI as the primary measure of efficacy, substantial and consistent reductions were observed following MMA, and adverse events were not commonly reported. Outcomes following pharyngeal surgeries were less consistent, and adverse events were more commonly reported.

The following is excerpted from the AASM practice parameters (Aurora, 2010):

• MMA, UPPP as a sole procedure or multi-level, or stepwise surgery following failed UPPP as a sole treatment - all received a recommendation of “Option” (uncertain clinical use), due to the lack of rigorous data evaluating surgical modifications of the upper airway;
• Radiofrequency Ablation (RFA) also received a recommendation of “Option” for individuals with mild to moderate OSA who cannot tolerate or who are unwilling to adhere to CPAP, or in whom oral appliances have been found ineffective or undesirable;
• Palatal implants received a recommendation of “Option” for those with mild OSA who failed medical therapy;
• LAUP was not recommended as a routine treatment for OSA (“Standard”).
• A recommendation of “Standard” was given for the determination of the presence and severity of OSA before initiating surgical therapy, discussion of success rates, complications, and alternative treatments with the individual, and a postoperative follow-up evaluation, which includes a clinical evaluation and an objective measure of the presence and severity of sleep-disordered breathing and oxygen saturation, although it was noted that little guidance was available in the medical literature to recommend any particular monitoring strategy nor optimal intervals and duration of follow-up.

UPPP

There is widespread agreement in the published studies of UPPP, as to the definition of "success" of the procedure. This is defined as a reduction in pre-operative AHI/RDI or Apnea index (AI) by at least 50% with a post UPPP AHI/RDI of less than 20; or a post UPPP AI less than 10. Using these definitions, a person whose pre-operative AHI/RDI/AI is less than 10 is already (by definition) "cured" of their OSA and is, therefore, not an appropriate candidate for UPPP. Furthermore, there is no published literature that supports the value of UPPP for this group.

Studies evaluating UPPP or modified UPPP as a sole treatment of OSA have reported decreased AHI from baseline maintained in the long-term, although several studies have showed a declining therapeutic effect over time (Friberg, 2020; Neruntarat, 2011; Sundman, 2021). In a meta-analysis, He and colleagues (2019) analyzed the long-term outcomes (at least 34 months) of UPPP as a sole treatment of OSA. A total of 11 studies were included. The mean AHI at baseline was 39.9 ± 18.3 in 6 studies and 43.2 ± 17.7 in 4 studies. Compared with the short-term studies, long-term studies showed a mean AHI increase of 12.3. Despite a decreasing curative effect, the mean AHI remained improved over baseline.

There is recognition in the literature that UPPP, when performed as the sole procedure, is less likely to be a success when severe OSA is present preoperatively. The AASM defines "severe" as an AHI/RDI greater than 30. There is evidence that UPPP, when performed for individuals with an AHI/RDI greater than 40, is unsuccessful in the vast majority of cases (Friedman, 2005; Millman, 2000). This may, in part, be related to the presence of unrecognized coexistent hypopharyngeal obstruction in persons with severe OSA that could not be expected to be adequately relieved by UPPP alone, which addresses only velopharyngeal (retropalatal) obstruction. Multilevel upper airway collapse, which is often present in those with OSA, may be only partially relieved by a single procedure (Yang, 2020).

There are a limited number of studies assessing the efficacy of multilevel surgery. Yang and associates (2020) compared the efficacy of hyoid myotomy and suspension with UPPP to CPAP therapy in individuals with moderate to severe OSA. In the case series study (n=15), individuals who failed or refused CPAP therapy underwent surgery. The results of each type of therapy were compared in the same individuals. While there were improvements in OSA severity and oxygen desaturation following both treatments, the individuals showed improved sleep stage, and blood pressure control during CPAP therapy.

The decreased efficacy over time is thought to be related to multiple factors, such as the tendency to gain weight as well as increased laxity in the tissue with age. Given the invasive nature of UPPP and the decreased efficacy over time, it is reasonable to limit use of this treatment to those who have failed non-invasive treatment with positive airway pressure therapy.

Soft Tissue Reconstruction

Hyoid myotomy and suspension, and mandibular osteotomy with genioglossus advancement have been demonstrated in multiple case series studies to provide significant relief of symptoms for individuals suffering from OSA where hypopharyngeal (retrolingual) obstruction during sleep is a significant factor (Song, 2016). These soft tissue reconstructive procedures have been shown to successfully alter the anatomy of persons with OSA sufficiently to prevent upper airway collapse. Not all individuals are appropriate for this procedure. Careful evaluation of the upper airway anatomy should take place prior to consideration of this procedure. As with UPPP, hyoid myotomy and suspension, and mandibular osteotomy with genioglossus advancement should not be used as first line treatments, and trials of conservative therapies, such as CPAP, should be attempted first. Hyoid myotomy and suspension, and mandibular osteotomy with genioglossus advancement may be performed, along with UPPP, in selected individuals where both velopharyngeal and hypopharyngeal obstruction during sleep are thought to occur.

A retrospective case series evaluating the surgical outcomes of individuals whose OSA was treated by UPPP and hyoid suspension was published in 2023 (van Tassel). A total of 39 individuals with moderate to severe OSA, obesity, and multiple levels of airway collapse and CPAP therapy failure or intolerance underwent staged or concurrent surgery. A polysomnogram was performed 3 to 9 months following surgery. At follow-up, the median AHI was reduced from 42.0 to 10.8 and the mean AHI declined significantly by 69.2% (49.9 ± 25.6 to 15.4 ± 14.9). Surgical success, defined as a final AHI of 20 or lower or a 50% or greater decline in AHI, was achieved in 76.9% (30/39). Only short-term outcomes were reported in this study.

Jaw Realignment Surgery

Jaw realignment surgery in individuals with OSA who are unresponsive to other therapies has been demonstrated to be an effective treatment. While the results of this procedure have been shown to significantly improve the symptoms of OSA, jaw realignment surgery involves extensive jaw reconstruction. Several articles in the peer-reviewed literature have proposed a stepwise approach to OSA therapy that requires the use of other conservative and surgical interventions, mainly CPAP and UPPP, prior to consideration of jaw realignment surgery.

A meta-analysis by Zaghi and colleagues (2016) evaluated the efficacy of maxillomandibular advancement as a treatment of OSA. A total of 45 studies with individual data from 518 participants were included. The primary outcomes were the changes in AHI and RDI following surgery. Following surgery, 98.8% (512/518) reported an improvement in AHI and RDI. Mean postoperative changes in AHI and RDI were -47.8 (25.0) and -44.4 (33.0), respectively. The majority of individuals had a history of prior surgery for OSA (197 of 268 [73.5%]). The authors noted, “patients with a high residual RDI and AHI after failure of other surgical procedures for sleep apnea are highly likely to benefit from MMA.”

This conservative approach is appropriate in all but the most extenuating circumstances involving severe maxillofacial malformations related to OSA. Studies have reported success rates of up to 100%, although most studies report a surgical success rate of approximately 80% and OSA cure rates of 30-40% (Al-Bayyati, 2025; Buller, 2020; Romano, 2020). The literature on this procedure indicates that success varies with the experience of the surgeon and the facility, and care should be taken in their selection.

RFVTR or LAUP

There is inadequate evidence in the published medical literature demonstrating the efficacy of radiofrequency (RF) ablation techniques for the treatment of OSA. One particular technique, RFVTR which focuses on the base of the tongue and soft palate and includes two procedures marketed as Somnoplasty and Coblation, has been described in the medical literature. In a multi-institutional study of 56 subjects with OSA treated with radiofrequency tongue base reduction, the mean pre-operative AHI index of 40.5 decreased only to 32.8 after treatment (Woodson 2001). A randomized controlled trial (RCT), involving 90 subjects with mild to moderate OSA, evaluated RFVTR of both tongue and palate in 30 individuals with comparisons to those receiving CPAP or sham radiofrequency treatment. Results showed that there was no significant reduction in either AHI or nocturnal oxygen desaturation in the RFVTR-treated group compared with the CPAP or sham groups (Woodson 2003). A systematic review and meta-analysis of 20 studies was done to evaluate the efficacy of temperature-controlled radiofrequency tissue ablation (TCRFTA) in treating OSA. TCRFTA was categorized based on location: base of tongue, soft palate and multilevel. Analysis showed significant reductions in RDI, Epworth Sleep Scale (ESS), lowest oxygen saturation (LSAT) and snoring for procedures performed at the base of the tongue. TCRFTA at the soft palate showed limited efficacy, although there was a paucity of studies in this area. Multilevel TCFFTA did show a significant reduction in RDI, in the short term. Analysis of AHI was not completed as this outcome was not consistently reported within the studies. The authors reported that the studies were generally of low quality and there was significant heterogeneity which did not allow strong conclusions (Baba, 2015). Studies with longer-term outcomes would be useful in evaluating the benefits of this procedure.

LAUP has primarily been researched as a treatment of snoring without associated clinically significant OSA. There are concerns that OSA may worsen following the LAUP procedure, or OSA may develop if LAUP is used to treat snoring (Camacho, 2017; Epstein, 2009; Franklin, 2009; Göktas, 2014). Camacho and associates (2017) performed a meta-analysis on the use of LAUP as a stand-alone treatment for OSA and concluded:

Statement of Significance

There are three important points. First, laser-assisted uvulopalatoplasty (LAUP) can potentially worsen obstructive sleep apnea (OSA; 44% of patients with individual data). Second, primary snoring patients who no longer snore after LAUP should be tested for OSA post-operatively if they develop signs and symptoms of OSA. Third, given that reflexogenic dilation of the pharyngeal airway is at least partially mediated by pharyngeal mucosa afferent nerve fibers, it is possible that by destroying the surface of the soft palate with a laser, that there may be blunting of the reflexogenic dilation of the pharyngeal airway. Therefore, LAUP should be performed with caution or not performed at all. Proper patient counseling is essential.

Franklin (2009) conducted a systematic review to evaluate the efficacy and adverse effects of surgery for snoring and OSA. The review included four RCTs of surgery versus either sham surgery or conservative treatment in adults, and described outcome measures for daytime sleepiness, QOL, AHI, and snoring. Results of this review found that there was no significant effect on daytime sleepiness and QOL following LAUP or RFVTR. The authors concluded that these studies did not provide evidence of therapeutic effect from LAUP or RFVTR on daytime sleepiness, apnea reduction, QOL, or snoring.

CAPSO

Llewellyn and associates (2018) performed a meta-analysis to evaluate the clinical outcomes of CAPSO used to treat OSA. The meta-analysis included individuals who underwent CAPSO as the sole treatment (n=80), CAPSO with tonsillectomy (n=92) and CAPSO with expansion pharyngoplasty (n=78). Each group saw a decrease in mean AHI from baseline to post procedure; CAPSO alone showed a 41.1% decrease, CAPSO with tonsillectomy reported a 61.7% decrease, and CAPSO with expansion pharyngoplasty recorded a 52.1% decrease. While the study noted post-operative decreases in AHI, there was limited data regarding the length of time the participants were followed. Additional limitations of the meta-analysis include a limited number of studies and participants, the presence of significant heterogeneity, and the lack of randomized studies available.

CAPSO has been suggested as a treatment of snoring or mild OSA. Evidence from earlier studies were limited by a focus on snoring rather than OSA, small size and poor outcomes (Mair, 2000; Wassmuth, 2000). The limited evidence available does not show that CAPSO provides equivalent clinical benefit when compared to the established alternatives.

ENCORE Tongue Suspension System

Additional treatment methods proposed for OSA utilize the ENCORE Tongue Suspension System (Siesta Medical, Inc., Los Gatos, CA) or the AIRvance (formerly the Repose) Bone-anchored Suspension System (Medtronic, Inc., Minneapolis, MN), and also injection snoreplasty. To date, these treatments have not been evaluated in large, controlled trials with long-term outcomes data. At this time, there is insufficient evidence to make any recommendation about the appropriate clinical use of either tongue base suspension systems or injection snoreplasty.

Pillar palatal implant system

The literature has been limited regarding the safety and efficacy of the Pillar palatal implant system for treating OSA. Friedman (2008) reported a single institution RCT involving 62 subjects with mild to moderate OSA who were selected based on "Friedman tongue position," soft palate size, and body mass index (BMI) less than 32. Only 29 participants actually received the palatal implant and follow-up analysis. A total of 26 participants underwent a "sham" procedure and analysis as the placebo group. Follow-up was performed at 3 months, and success was defined as an AHI reduction of at least 50% and a post-procedure AHI less than 20. On this basis, 13/29 subjects receiving the implants were a success (44.8%), compared to 0 in the placebo group. However, 4 of the 13 "successes" already had a pre-procedure AHI of less than 20, as did 9 of the 26 in the placebo group. In the implant group, the mean AHI fell from 23.8 to 15.9, this latter number still representing moderate OSA, (as defined by the AASM). In addition, the mean Epworth Sleepiness Scale score fell from 12.7 to 10.2, the latter continuing to represent excessive daytime sleepiness (greater than 10). No individual data were reported, and it is unknown if OSA was completely relieved (AHI less than 5) in any of the trial participants. Mean minimum O₂ saturation rose from 88.3% to 89.7% (significance unclear) with QOL responses following treatment that were measured using an SF 36 rather than a more specific sleep-related QOL measurement tool. Acknowledged limitations of the study by the authors were the short follow-up (which precludes conclusions regarding the durability of the implant procedure) and the potential challenge in generalizing results arising from a limited study population of non-obese, mild to moderate OSA subjects with specific oral physical characteristics where half of the participants evaluated did not qualify for the study.

The available studies to date do not provide convincing evidence of the long-term efficacy of palatal implants in persons with OSA. The studies are restricted by small size, missing data, limited follow-up and large numbers of drop-outs within the study (Friedman, 2008; Walker, 2007). Walker (2007) reported a substantial number of individuals who experienced an increase in mean AHI at 90 days post-procedure compared to pre-procedure. Larger randomized controlled trials with longer follow-up and more complete participant data post-procedure are required to establish the procedure's efficacy for OSA.

Transpalatal advancement pharyngoplasty (TAP or TPAP)

Another technique that has been proposed as a surgical alternative for the treatment of OSA is TAP or TPAP. This surgical procedure alters the retro-palatal airway by advancing the palate forward without requiring excision of the soft palate. This procedure pulls the palate forward and superiorly. Conceptually, similarities exist to maxillary advancement without the associated alterations in dentition. The TAP procedure has been purported for use alone or in combination with other soft tissue surgeries for individuals with narrowing in the retro-palatal airway, especially narrowing proximal to the point of palatal excision using traditional UPPP techniques. A transpalatal approach and advancement has also been proposed for individuals with obstructions in the nasopharynx, such as enlarged adenoids, that cannot be accessed through traditional techniques. In a meta-analysis and systematic review, Volner and colleagues (2017) evaluated the effect of TPAP on the AHI and lowest oxygen saturation (LSAT). Studies were included when TPAP was used to treat OSA and no other surgeries addressing other levels of obstruction were performed at the same time. A total of 5 studies dating from 1993 to 2014 with 199 participants were included. The relative reduction in AHI was 64.8% (mean ± standard deviation of 54.6 ± 23.0 [95 % confidence interval (CI), 51.4, 57.8] to 19.2 ± 16.8 [95 % CI, 16.9, 21.5] events/hour). The mean LSAT difference improved from 81.9 ± 8.1 to 85.4 ± 6.9 with a mean difference of 3.55. However, only 70 participants had data available regarding the LSAT and when one study was removed from the analysis, the mean difference was 0.62. There were multiple limitations associated with analysis including the quality of the studies, the lack of comparison with other surgical procedures and the potential for author bias (the individual who developed the procedure authored 3 of the studies). A retrospective review not included in the analysis described 30 subjects who underwent a TAP procedure; 20 of these study subjects also had various tongue-base procedures performed at the same time as TAP (Woodson, 2005). Only 10 had TAP alone. The results of postoperative AHI in these 30 subjects were better than a comparable group of 44 subjects undergoing UPPP, 26 of whom had UPPP as the sole procedure. Also, for the subjects in each group who did not have additional tongue base surgery, the AHI improved significantly more in the TAP treated group (n=10) than the UPPP treated group (n=26). Larger studies are needed to establish the safety/efficacy of the TAP procedure, together with prospective comparisons with established palate-based surgical techniques.

Cryolysis reduction of the tongue and soft palate

Gonzales and associates (2025) summarize OSA treatment noting:

Treatment has evolved to include solutions to either actively move obstructive tissue out of the airway (positive airway pressure therapy, hypoglossal nerve stimulation) or surgically remove the obstructive tissue from the airway (glossectomy, uvulopalatopharyngoplasty [UPPP], RF ablation). Both approaches have demonstrated efficacy but are limited by the need for nightly adherence and/or the associated surgical risks, respectively.

The Cryosa^™ System (Cryosa, Arden Hills, MN) is a minimally invasive device that uses controlled cooling to ablate excess tissue of the tongue and soft palate to treat moderate to severe OSA. This procedure is called submucosal cryolysis. The system is not yet available outside of clinical trials in the United States. The ARCTIC trials (NCT06008626 and NCT05542082) are prospective, multicenter, non-randomized single-arm studies currently underway to assess the safety and effectiveness of the procedure. There is currently no published evidence regarding clinical outcomes resulting from submucosal cryolysis.

Failure of CPAP Therapy

CPAP is considered the standard of care for the treatment of moderate to severe OSA. PAP therapy provides pneumatic splinting of the upper airway in order to allow for passive distention (Kushida, 2006). PAP therapy is a noninvasive and effective treatment with minor, reversible side effects. The effectiveness of PAP therapy is limited by adherence to treatment. The Centers for Medicare and Medicaid Services (CMS) defines PAP adherence as “4 or more hours of PAP usage per night for 70% of night in a 30-day period” (Naik, 2019). The use of PAP therapy to treat OSA in individuals with an AHI of 15 or greater is ‘plausible and clinically important” and is based on “reasonably strong epidemiologic evidence that this condition increases the risk of hypertension and cardiovascular morbidity” (CMS, 2001). The use of PAP therapy for at least 4 hours a night has become an established standard component of PAP therapy adherence and has been shown to have some validity as a measure of clinical significance (Sangal, 2020; Weaver, 2008; Wozniak, 2014).

Individuals cite multiple reasons for lack of adherence to PAP therapy including dry mouth, congestion, runny nose or nose bleeds, headaches, bloating, air leaks around the mask and difficulty breathing against airway pressure. Modifications to PAP therapy, trial of other masks, humidification and pressure modification devices may be an option for some individuals (Kennedy, 2019). Other individuals cite conditions such as anxiety or claustrophobia as barriers to PAP therapy. Desensitization programs or the use of less restrictive interface devices may improve adherence in some individuals (Khot, 2022).

An international consensus statement on OSA (Chang, 2023) sums up conditions surrounding CPAP failure:

CPAP nonadherence is complex and multifactorial, influenced by many factors including patient knowledge, perception of treatment and disease state, bed partner involvement, and mask interface. When counseling patients about surgical candidacy and surgical options, individualized discussion on experiences with CPAP and acceptance of CPAP as a long-term solution for OSA are important components of the shared decision making process.

Description of Sleep Apnea

OSA syndrome affects over 39 million people in the United States (US). Many of these people have never had a proper diagnosis. OSA is characterized by an interruption of breathing during sleep, due to airway obstruction or collapse. The obstruction may occur at one or at multiple levels such as retropalatal, retrolingual, or nasal cavity. OSA is often linked to obesity and decreased muscle tone due to aging. When the airway becomes blocked, a drop in blood oxygen content can occur which is detected by the brain, causing the individual to wake just enough to tighten the airway muscles and allow breathing to then resume. This may occur several hundred times in one night. OSA can cause many symptoms, such as depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work or driving. OSA is recognized as a contributor or primary mediators in several cardiovascular conditions, including atrial fibrillation, stroke, myocardial infarction and sudden cardiac death. Continuous positive airway pressure (CPAP) is considered the gold standard treatment for OSA and an estimated 33 million US adults use a CPAP machine. However, compliance is an issue with an estimated 40-70% of individuals using CPAP less than a therapeutic amount of time (Soose, 2016). There is also a subset of individuals who do not respond adequately to CPAP therapy. Surgical treatment is considered a second-line therapy following failure of PAP trial in most cases. Surgical treatment requires that a thorough preoperative evaluation be done to locate the precise area of obstruction as obstruction can occur at the retropalatal or the retrolingual area or in both areas (Aurora, 2010).

Description of OSA Treatments

UPPP is a surgical procedure involving the removal of excessive tissue in the retropharyngeal area, including tonsils and uvula, to widen the area to increase airflow. Since its inception, a number of modifications have been developed including lateral pharyngoplasty, uvulopalatal flap, Z-palatopharyngoplasty, palatal advancement pharyngoplasty, expansion sphincter pharyngoplasty, relocation pharyngoplasty and zed-plasty. While these techniques vary in their approach, the goal in all cases is to remove or reshape the tonsils. Complications of this surgery may include swelling, pain, infection, bleeding, reflux of secretions into the nose, and a nasal quality to the voice. This procedure typically requires an inpatient stay and is used for the treatment of severe OSA. This procedure can be used alone or when there is multilevel obstruction, as part of a staged procedure.

Hyoid myotomy is a surgical procedure that involves movement of the hyoid bone in the neck. The hyoid bone is a c-shaped bone located above the Adam’s apple, to which the base of the tongue and other soft tissues of the throat are anchored. Hyoid myotomy involves the surgical detachment of these soft tissues from the hyoid bone and then reattachment in a manner that places increased tension on the tissues. This increased tension is intended to decrease soft tissue collapse of the upper airway that is characteristic of sleep apnea. The Airlift^™ system (Siesta Medical; Los Gatos, CA) is a system of implants and instruments used to permanently lift and suspend the hyoid bone, allowing for expansion of the airway during sleep.

Genioglossus advancement is a surgical procedure that involves alteration of the anchor point for the genioglossus muscle of the tongue. This point is located on the inside of the lower jaw. During this procedure, the area of bone surrounding the anchor point is separated from the rest of the jawbone and pulled outward, drawing the tongue away from the back of the throat. This serves to prevent the base of the tongue from blocking the upper airway during sleep.

Jaw realignment surgery is an extensive procedure, in which the upper and lower jaws are advanced several millimeters to improve airflow through the back of the throat. Maxillomandibular advancement (MMA) involves bilateral sagittal split advancement of the mandible and a concurrent Le Fort I advancement of the maxilla. Several surgeries may be required. Persons undergoing jaw realignment surgery typically also undergo orthodontic therapy to correct changes in tooth alignment, associated with the surgery. Change in facial appearance is common in this type of surgery. Other side effects of the procedure include swelling, pain, dental mal-alignment requiring correction, and bleeding.

Many other surgical methods have been proposed for the treatment of OSA, which use various methods of removing or ablating excess tissue from the upper airway, predominantly the soft palate and in some cases the base of the tongue. Of these proposed methods, radiofrequency ablation techniques use high frequency radio waves to destroy tissue of the soft palate, nasal turbinates and/or base of the tongue to decrease excess tissues in the back of the throat. Radiofrequency ablative techniques include RFVTR, Coblation and Somnoplasty. Persons undergoing these procedures frequently require multiple treatments for adequate results. Another category of treatment that aims to remove excess tissue from the upper airway uses heat from either a laser or an electrocautery device to destroy tissue of the soft palate. The two approaches currently available that use this method are LAUP and CAPSO. CAPSO involves denuding the anterior aspect of the soft palate with a blended cautery followed by cauterization of that tissue to further stiffen the palate. CAPSO has been suggested as a less invasive and painful technique compared to other surgical procedures of the palate (Llewellyn, 2018).

Another surgical method proposed for the treatment of OSA is the AIRvance (formerly the Repose) system. This system involves the insertion of a bone screw into the inside of the lower jaw. A cable is then threaded through the base of the tongue and anchored to the bone screw. This system is used to prevent the base of the tongue from falling into the airway, which can be a cause of some OSA symptoms. Similar to the AIRvance System, the ENCORE Tongue Suspension System utilizes a suture loop which is created in the posterior section of the tongue base and is then tensioned and anchored with a bone screw placed midline on the infero-posterior surface of the mandible. The ENCORE System was cleared by the FDA on July 1, 2011 through the 510(k) approval process as an intraoral device for anterior advancement of the tongue base by means of a bone screw threaded with a suture. It is indicated for the treatment of mild or moderate OSA and/or snoring. The literature, to date, has been limited by small numbers of subjects, and a literature review conducted by the manufacturer of the ENCORE System concluded that the evidence currently available has been graded as low-level evidence regarding safety and efficacy (Sezen, 2011).

Injection snoreplasty has been proposed as a treatment of both snoring and OSA. This procedure, frequently done in one to three separate treatments, involves injection of a chemical (Sotradecol) into the soft palate and uvula. Sotradecol is known as a sclerotherapy agent, and causes scarring via an inflammatory reaction in the tissues to which it is exposed. The scarring caused by Sotradecol causes the flabby loose tissue in the back of the throat to shrink and tighten, which is proposed to open the upper airway and decrease the symptoms of snoring and OSA.

The Pillar Palatal Implant System (Restore Medical, Inc. St. Paul, MN) consists of three narrow threads of braided polyester slightly less than an inch in length that are inserted under the skin of the soft palate, using a delivery tool. One is placed in the midline and one each in right and left lateral locations. The procedure can be performed in the physician’s office under local anesthesia, and over the next few weeks, scar tissue grows around the threads further stiffening the palate. The implants are designed to be permanent structures but can be removed if necessary for reasons of infection or instability. Post-operative pain is claimed to be mild and short lived with rapid resumption of normal activities and diet (unlike LAUP and RFVTR). The Pillar system received market clearance from the U.S. Food & Drug Administration in 2003. Common complications include implant extrusion, pain, sensation of a foreign body, cellulitis and difficulty swallowing (Povolotski, 2020).

Potential Risks

The level of risk associated with the various methods of OSA treatment varies dependent upon the level of invasiveness. The use of oral appliances poses little risk, but proper fitting should be done to assure optimal efficacy. The risks associated with CPAP and its derivatives are not life threatening but include disturbed sleep until the user is acclimated to the device.

Various surgical treatments for OSA all include the standard risks associated with all surgical treatments, including infection, bleeding, pain and discomfort. Not all procedures are guaranteed to be 100% successful, and results may vary. All of these surgeries result in permanent reconfiguration of the anatomical position of the upper airway, which may have unintended consequences. Persons undergoing jaw realignment should be especially aware that this surgery will most likely affect their appearance.

Apnea-Hypopnea index (AHI) or Respiratory disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep. For the purposes of this document, the terms AHI and RDI are interchangeable, although they may differ slightly in clinical use.

Central sleep apnea (CSA): Sleep apnea caused by decreased respiratory center output in the brain. This sleep apnea syndrome is not as common as OSA but may be associated with similar symptoms.

Continuous positive airway pressure (CPAP): Noninvasive treatment for OSA that involves delivery of pressurized air during sleep through a device that snugly covers the nose. Considered the gold standard treatment of OSA.

Obstructive sleep apnea (OSA): A condition which is characterized by cessation of breathing during sleep, caused by temporary collapse of the upper airway.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Uvulopalatopharyngoplasty (UPPP), Soft Tissue Reconstruction, Jaw Realignment Surgery
When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, or when the code describes a procedure indicated in the Position Statement section as not medically necessary, or for the following diagnosis:

Other procedures
When services are Not Medically Necessary:

When services are Investigational and Not Medically Necessary:
For the procedures listed above, for all other diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:

Peer Reviewed Publications:

1. Al-Bayyati HHR, Hassing GJ, van der Hoeve EP, et al. Patient-reported outcomes with focus on health-related quality of life in patients with obstructive sleep apnea treated with maxillomandibular advancement surgery: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2025; 83(5):543-557.
2. Alkhalil M, Lockey R. Pediatric obstructive sleep apnea syndrome (OSAS) for the allergist: update on the assessment and management. Ann Allergy Asthma Immunol. 2011; 107(2):104-109.
3. Baba RY, Mohan A, Metta VV, Mador MJ. Temperature controlled radiofrequency ablation at different sites for treatment of obstructive sleep apnea syndrome: a systematic review and meta-analysis. Sleep Breath. 2015; 19(3):891-910.
4. Back 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. 2009; 119(8):1621-1627.
5. Benninger M, Walner D. Obstructive sleep-disordered breathing in children. Clin Cornerstone. 2007; 9 Suppl 1:S6-12.
6. Bertoletti F, Indelicato A, Banfi P, Capolunghi B. Sleep apnoea/hypopnea syndrome: combination therapy with the Pillar palatal implant technique and continuous positive airway pressure (CPAP). A preliminary report. B-ENT. 2009; 5(4):251-257.
7. Boudewyns A, Van De Heyning P. Temperature-controlled radiofrequency tissue volume reduction of the soft palate (somnoplasty) in the treatment of habitual snoring: results of a European multicenter trial. Acta Otolaryngol. 2000; 120(8):981-985.
8. Brietzke SE, Mair EA. Injection snoreplasty: extended follow-up and new objective data. Otolaryngol Head Neck Surg. 2003; 128(5):605-615.
9. Browaldh N, Bring J, Friberg D. SKUP(3) RCT; continuous study: changes in sleepiness and quality of life after modified UPPP. Laryngoscope. 2016; 126(6):1484-1491.
10. Buller M, Jodeh DS, Rottgers SA. Maxillomandibular advancement for the treatment of obstructive sleep apnea in patients with normal or class I malocclusion. J Craniofac Surg. 2020; 31(3):716-719.
11. Camacho M, Nesbitt NB, Lambert E, et al. Laser-assisted uvulopalatoplasty for obstructive sleep apnea: a systematic review and meta-analysis. Sleep. 2017; 40(3).
12. Choi JH, Kim SN, Cho JH. Efficacy of the Pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apnea: a meta-analysis. Laryngoscope. 2013; 123(1):269-276.
13. Darrow DH. Surgery for pediatric sleep apnea. Otolaryngol Clin North Am. 2007; 40(4):855-875.
14. De Kermadec H, Blumen MB, Engalenc D, et al. Radiofrequency of the soft palate for sleep-disordered breathing: a 6-year follow-up study. Eur Ann Otorhinolaryngol Head Neck Dis. 2014; 131(1):27-31.
15. DeRowe A, Gunther E, Fibbi A, et al. Tongue-base suspension with a soft tissue-to-bone anchor for obstructive sleep apnea: preliminary clinical results of a new minimally invasive technique. Otolaryngol Head Neck Surg. 2000; 122(1):100-103.
16. Dubin MG, Senior BA. The limitations of isolated palatal surgery for patients with obstructive sleep apnea. Otolaryngol Clin North Am. 2003; 36(3):511-517.
17. Elshaug AG, Moss JR, Southcott AM, Hiller JE. Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence. Sleep. 2007; 30(4):461-467.
18. Farrar J, Ryan J, Oliver E, et al. Radiofrequency ablation for the treatment of obstructive sleep apnea: a meta-analysis. Laryngoscope. 2008; 118(10):1878-1883.
19. 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. 2003; 167(1):15-19.
20. Ferguson M, Smith TL, Zanation AM, Yarbrough WG. Radiofrequency tissue volume reduction: multilesion vs. single-lesion treatments of snoring. Arch Otol Laryngol, Head Neck. 2001; 127(9):1113-1118.
21. Fernandez-Julian E, Munoz N, Achiques MT, et al. Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2009; 140(6):917-923.
22. Fibbi A, Ameli F, Brocchetti F, et al. Tongue base suspension and radiofrequency volume reduction: a comparison between 2 techniques for the treatment of sleep-disordered breathing. Am J Otolaryngol. 2009; 30(6):401-406.
23. Franklin KA, Anttila H, Axelsson S, et al. Effects and side-effects of surgery for snoring and obstructive sleep apnea - a systematic review. Sleep. 2009; 32(1):27-36.
24. Friberg D, Sundman J, Browaldh N. Long-term evaluation of satisfaction and side effects after modified uvulopalatopharyngoplasty. Laryngoscope. 2020; 130(1):263-268.
25. Friedman M, Ibrahim H, Lee G, et al. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2003; 129(6):611-621.
26. Friedman M, Schalch P, Lin HC, et al. Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome. Otolaryn Head Neck Surg. 2008; 138(2):209-216.
27. Friedman M, Vidyasagar R, Bliznikas D, Joseph N. Does severity of obstructive sleep apnea/hypopnea syndrome predict uvulopalatopharyngoplasty outcome? Laryngoscope. 2005; 115(12):2109-2113.
28. Friedman M, Vidyasagar R, Bliznikas D, Joseph NJ. Patient selection and efficacy of pillar implant technique for treatment of snoring and obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2006; 134(2):187-196.
29. Gillespie MB, Wylie PE, Lee-Chiong T, Rapoport DM. Effect of palatal implants on continuous positive airway pressure and compliance. Otolaryngol Head Neck Surg. 2011; 144(2):230-236.
30. Giménez S, Altuna M, Blessing E, et al. Sleep disorders in adults with Down syndrome. J Clin Med. 2021; 10(14):3012.
31. Göktas Ö, Solmaz M, Göktas G, Olze H. Long-term results in obstructive sleep apnea syndrome (OSAS) after laser-assisted uvulopalatoplasty (LAUP). PLoS One. 2014; 9(6):e100211.
32. Gonzales D, Morris CE, Kannan S, et al. Selective adipose cryolysis for reduction of lingual tissue in a porcine model. Otolaryngol Head Neck Surg. 2025; 172(3):1053-1062.
33. Guilleminault C, Lee JH, Chan A. Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med. 2005; 159(8):775-785.
34. He M, Yin G, Zhan S, et al. Long-term efficacy of uvulopalatopharyngoplasty among adult patients with obstructive sleep apnea: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2019; 161(3):401-411.
35. Hoban TF, Chervin RD. Sleep-related breathing disorders of childhood: description and clinical picture, diagnosis, and treatment approaches. Sleep Med Clin. 2007; 2(3):445-462.
36. Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2010; 14(5):287-297.
37. Huntley C, Chou DW, Doghramji K, Boon M. Comparing upper airway stimulation to expansion sphincter pharyngoplasty: a single university experience. Ann Otol Rhinol Laryngol. 2018; 127(6):379-383.
38. Huntley C, Topf MC, Christopher V, et al. Comparing upper airway stimulation to transoral robotic base of tongue resection for treatment of obstructive sleep apnea. Laryngoscope. 2019; 129(4):1010-1013.
39. Ibrahim B, de Freitas Mendonca MI, Gombar S, et al. Association of systemic diseases with surgical treatment for obstructive sleep apnea compared with continuous positive airway pressure. JAMA Otolaryngol Head Neck Surg. 2021; 147(4):329-335.
40. Kennedy B, Lasserson TJ, Wozniak DR, Smith I. Pressure modification or humidification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2019; 12(12):CD003531.
41. Khot SP, Barnett HM, Davis AP, et al. Novel and modifiable factors associated with adherence to continuous positive airway pressure therapy initiated during stroke rehabilitation: an exploratory analysis of a prospective cohort study. Sleep Med. 2022; 97:43-46.
42. Kuhnel T, Schurr C, Wagner B, Geisler P. Morphological changes of the posterior airway space after tongue base suspension. Laryngoscope. 2005; 115(3):475-480.
43. Kushida CA, Littner MR, Hirshkowitz M, et al.; American Academy of Sleep Medicine. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep. 2006; 29(3):375-380.
44. Li KK, Powell NB, Riley RW, et al. Temperature-controlled radiofrequency tongue base reduction for sleep-disordered breathing; long term outcomes. Otolaryngol Head Neck Surg. 2002; 127(3):230-234.
45. Li KK. Surgical management of obstructive sleep apnea. Clin Chest Med. 2003: 24(2):365-370.
46. Lin CM, Davidson TM, Ancoli-Israel S. Gender differences in obstructive sleep apnea and treatment implications. Sleep Med Rev. 2008; 12(6):481-496.
47. Llewellyn CM, Noller MW, Camacho M. Cautery-assisted palatal stiffening operation for obstructive sleep apnea: a systematic review and meta-analysis. World J Otorhinolaryngol Head Neck Surg. 2018; 5(1):49-56.
48. Mair, EA, Day RH. Cautery-assisted palatal stiffening operation. Otolaryngol Head Neck Surg. 2000; 122(4):547-556.
49. Marcus CL, Rosen G, Ward SL, et al. Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea. Pediatrics. 2006; 117(3):e442-451.
50. Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest. 2004; 125(4):1270-1278.
51. Maurer JT, Verse T, Stuck BA, et al. Palatal implants for primary snoring: short-term results of a new minimally invasive surgical technique. Otolaryngol Head Neck Surg. 2005; 132(1):125-131.
52. Mehta A, Qian J, Petocz P, et al. A randomized controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med. 2001; 163(6):1457-1461.
53. Miller FR, Watson D, Malis D. Role of the tongue base suspension suture with the Repose System bone screw in the multilevel surgical management of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2002; 126(4):392-398.
54. Millman RP, Carlisle CC, Rosenberg C, et al. Simple predictors of uvulopalatopharyngoplasty outcome in the treatment of obstructive sleep apnea. Chest. 2000; 118(4):1025-1030.
55. Mulholland GB, Jeffery CC, Ziai H, et al. Multilevel palate and tongue base surgical treatment of obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope. 2019; 129(7):1712-1721.
56. Naik S, Al-Halawani M, Kreinin I, Kryger M. Centers for Medicare and Medicaid Services positive airway pressure adherence criteria may limit treatment to many Medicare beneficiaries. J Clin Sleep Med. 2019; 15(2):245-251.
57. Nelson LM. Combined temperature-controlled radiofrequency tongue reduction and UPPP in apnea surgery. Ear Nose Throat J. 2001; 80(9):640-644.
58. Neruntarat C. Uvulopalatal flap for obstructive sleep apnea: short-term and long-term results. Laryngoscope. 2011; 121(3):683-687.
59. Nordgård S, Hein G, Stene BK, et al. One-year results: palatal implants for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007; 136(5):818-822.
60. Omur M, Ozturan D, Elez F, et al. Tongue base suspension combined with UPPP in severe OSA patients. Otolaryngol Head Neck Surg. 2005; 133(2):218-223.
61. Pang KP, Terris DJ. Modified cautery-assisted palatal stiffening operation: new method for treating snoring and mild obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007; 136(5):823-826.
62. Petrov ME, Lichstein KL. Differences in sleep between black and white adults: an update and future directions. Sleep Med. 2016; 18:74-81.
63. Povolotskiy R, Abraham ME, Leverant AB, et al. Complications of palatal pillar implants: an analysis of the MAUDE database and literature review. Am J Otolaryngol. 2020; 41(1):102303.
64. Qureshi A, Ballard RD. Obstructive sleep apnea. J Allergy Clin Immunol. 2003; 112(4):643-651.
65. Romano M, Karanxha L, Baj A, et al. Maxillomandibular advancement for the treatment of obstructive sleep apnoea syndrome: a long-term follow-up. Br J Oral Maxillofac Surg. 2020; 58(3):319-323.
66. Sangal RB, Sudan N. Baseline lighter sleep and lower saturation are associated with improved sleepiness and adherence on continuous rather than autotitrating positive airway pressure. Clin EEG Neurosci. 2020; 51(3):174-179.
67. Server EA, Alkan Z, Yiğit Ö, Yasak AG. Long-term results of pillar implant procedure. Kulak Burun Bogaz Ihtis Derg. 2016; 26(5):258-64.
68. Sezen OS, Aydin E, Eraslan G, et al. Modified tongue base suspension for multilevel or single level obstructions in sleep apnea: Clinical and radiologic results. Auris Nasus Larynx. 2011; 38:487-494.
69. Shah J, Russell JO, Waters T, et al. Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: a single institution experience. Am J Otolaryngol. 2018; 39(3):266-270.
70. Sher AE, Flexon PB, Hillman D, et al. Temperature-controlled radiofrequency tissue volume reduction in the human soft palate. Otolaryngol Head Neck Surg. 2001; 125(4):312-318.
71. Sher AE. Upper airway surgery for obstructive sleep apnea. Sleep Med Rev. 2002; 6(3):195-212.
72. Silverberg D, Iaina A. Treating obstructive sleep apnea improves essential hypertension and quality of life. Am Fam Phys. 2002; 65(2):229-236.
73. Song SA, Wei JM, Buttram J, et al. Hyoid surgery alone for obstructive sleep apnea: asystematic review and meta-analysis. Laryngoscope. 2016; 126(7):1702-1708.
74. Steward DL. Effectiveness of multilevel (tongue and palate) radiofrequency tissue ablation for patients with obstructive sleep apnea syndrome. Laryngoscope. 2004a; 114(12):2073-2084.
75. Steward DL, Huntley TC, Woodson BT, et al. Palate implants for obstructive sleep apnea: multi-institution, randomized, placebo-controlled study. Otolaryngol Head Neck Surg. 2008; 139(4):506-510.
76. Steward DL, Weaver EM, Woodson BT. A comparison of radiofrequency treatment schemes for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2004b; 130(5):579-585.
77. Strollo PJ. Indications for treatment of obstructive sleep apnea in adults. Clin Chest Med. 2003; 24(2):307-313.
78. Stuck BA, Maurer JT, Hormann K. Tongue base reduction with radiofrequency tissue ablation: preliminary results after two treatment sessions. Sleep Breath. 2000; 4(4):155-162.
79. Stuck BA, Maurer JT, Verse T, Hormann K. Tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction for treatment of obstructive sleep apnea syndrome. Acta Otolaryngol. 2002; 122(5):531-536.
80. Sundman J, Browaldh N, Fehrm J, Friberg D. Eight-year follow-up of modified uvulopalatopharyngoplasty in patients with obstructive sleep apnea. Laryngoscope. 2021; 131(1):E307-E313.
81. Terris DJ, Kunda LD, Gonella MC. Minimally invasive tongue base surgery for obstructive sleep apnea. J Laryngol Otol. 2002; 116(9):716-721.
82. Terris DJ, Coker JF, Thomas A J, Chavoya M. Preliminary findings from a prospective, randomized trial of two palatal operations for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002; 127(4):315-323.
83. 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. 2003; 129(5):539-546.
84. Troell RJ. Radiofrequency techniques in the treatment of sleep-disordered breathing. Otolaryngol Clin North Am. 2003; 36(3):473-493.
85. van den Broek E, Richard W, van Tinteren H, et al. UPPP combined with radiofrequency thermotherapy of the tongue base for the treatment of obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol. 2008; 265(11):1361-1365.
86. Van Tassel J, Chio E, Silverman D, et al. Hyoid suspension with UPPP for the treatment of obstructive sleep apnea. Ear Nose Throat J. 2023; 102(5):NP212-NP219.
87. Vicini C, Dallan I, Campanini A, et al. Surgery vs. ventilation in adult severe obstructive sleep apnea syndrome. Am J Otolaryngol. 2010; 31(1):14-20.
88. Volner K, Dunn B, Chang ET, et al. Transpalatal advancement pharyngoplasty for obstructive sleep apnea: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2017; 274(3):1197-1203.
89. Walker RP, Levine HL, Hopp ML, Greene D. Extended follow-up of palatal implants for OSA treatment. Otolaryngol Head Neck Surg. 2007; 137(5):822-827.
90. Wassmuth Z, Mair E, Loube D, Leonard D. Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2000; 123(1 Pt 1):55-60.
91. Watanabe T, Kumano-Go T, Suganuma N, et al. The relationship between esophageal pressure and apnea hypopnea index in obstructive sleep apnea-hypopnea syndrome. Sleep Res Online. 2000; 3(4):169-172.
92. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008; 5(2):173-178.
93. Woodson BT. Transpalatal advancement pharyngoplasty. Oper Tech Otolaryn. 2007; 18(1):11-16.
94. Woodson BT, Derowe A, Hawke M, et al. Pharyngeal suspension suture with repose bone screw for obstructive sleep apnea. Otolaryngol Head Neck Surg. 2000; 122(3):395-401.
95. Woodson BT, Nelson L, Mickelson S, et al. A multi-institutional study of radiofrequency volumetric tissue reduction for OSAS. Otolaryngol Head Neck Surg. 2001; 125(4):303-311.
96. Woodson BT, Robinson S, Lim HJ. Transpalatal advancement pharyngoplasty outcomes compared with uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 2005; 133(2):211-217.
97. Woodson BT, Steward DL, Mickelson S, et al. Multicenter study of a novel adjustable tongue-advancement device for obstructive sleep apnea. Otolaryngol Head Neck Surg. 2010; 143(4):585-590.
98. Woodson BT, Steward DL, Weaver EM, Javaheri S. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2003; 128(6):848-861.
99. Wozniak DR, Lasserson TJ, Smith I. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2014; (1):CD007736.
100. Yang MC, Hsu YB, Lan MY, Lan MC. The comparison of multilevel surgery (hyoid myotomy and suspension with uvulopalatopharyngoplasty) with CPAP in moderate to severe OSAS patients. Eur Arch Otorhinolaryngol. 2020; 277(8):2349-2355.
101. Zaghi S, Holty JE, Certal V, et al. Maxillomandibular advancement for treatment of obstructive sleep apnea: A meta-analysis. JAMA Otolaryngol Head Neck Surg. 2016; 142(1):58-66.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS). Position Statements: Available at: http://www.entnet.org/content/position-statements. Accessed on July 16, 2025.
   • Midline Glossectomy for OSA. Revised April 22, 2021.
   • Submucosal Ablation of the Tongue Base for OSAS. April 22, 2021.
   • Surgical Management of Obstructive Sleep Apnea. April 22, 2021.
   • Tongue Based Procedures. November 24, 2021.
   • Tongue Suspension. April 21, 2021.
   • Treatment of Obstructive Sleep Apnea. Revised April 22, 2021.
   • Uvulopalatopharyngoplasty. Revised April 22, 2021.
2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Indications for orthognathic surgery. 2020. Available at: https://aaoms.org/wp-content/uploads/2025/01/ortho_indications.pdf. Accessed on June 11, 2025.
3. Aurora RN, Casey KR, Kristo D, et al. American Academy of Sleep Medicine. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010; 33(10):1408-1413.
4. Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010; 33(10):1396-1407.
5. Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis, Decision Memo. Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea. CAG-00093N. October 30, 2001. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=204&fromdb=true. Accessed on July 16, 2025.
6. Chang JL, Goldberg AN, Alt JA, et al. International consensus statement on obstructive sleep Apnea. Int Forum Allergy Rhinol. 2023; 13(7):1061-1482.
7. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5(3):263-276.
8. Giralt-Hernando M, Valls-Ontañón A, Guijarro-Martínez R, et al. Impact of surgical maxillomandibular advancement upon pharyngeal airway volume and the apnoea-hypopnoea index in the treatment of obstructive sleep apnoea: systematic review and meta-analysis. BMJ Open Respir Res. 2019; 6(1):e000402.
9. Marcus CL, Brooks LJ, Draper KA, et al.; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012; 130(3):e714-755.
10. National Library of Medicine (NIH). Cryosa, Inc. Accessed on July 16, 2025.
    • Multicenter Pilot Study of the Cryosa System for the Treatment of Obstructive Sleep Apnea. NLM Identifier: NCT06008626. Last updated on November 27, 2024. Available at: https://clinicaltrials.gov/study/NCT06008626.
    • OUS Multicenter Pilot Study of the CHILLS Cryotherapy System for the Treatment of Obstructive Sleep Apnea (ARCTIC-2), NLM Identifier: NCT05542082. Last updated on June 26, 2025. Available at: https://clinicaltrials.gov/study/NCT05542082?term=NCT05542082&rank=1.
11. Qaseem A, Holty JC, Owens DK, et al. American College of Physicians (ACP). Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013; 159(7):471-483.
12. Randerath WJ, Verbraecken J, Andreas S, et al. European Respiratory Society task force on non-CPAP therapies in sleep apnea. Non-CPAP therapies in obstructive sleep apnea. Eur Respir J. 2011; 37(5):1000-1028.
13. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008; 52(8):686-717.
14. Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev. 2005;(4):CD001004.
15. U.S. Food and Drug Administration (FDA) Center for Devices and Radiologic Health (CDRH) 510 (k) Premarket Notification Database. Accessed on July 20, 2025.
    • Encore™ Bone Screw System. Summary of Safety and Effectiveness. No.K183310. Rockville, MD: FDA. May 9, 2019. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K183310.
    • ENCORE^™ Tongue Suspension System. Summary of Safety and Effectiveness. No. K111179. Rockville, MD: FDA. July 1, 2011. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf11/K111179.pdf.
    • Pillar^™ Palatal Implant System. Summary of Safety and Effectiveness. No. K040417. Rockville, MD: FDA. July 28, 2004. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf4/K040417.pdf.

1. American Academy of Otolaryngology - Head and Neck Surgery. Snoring, Sleeping Disorders, and Sleep Apnea. Available at: https://www.enthealth.org/conditions/snoring-sleeping-disorders-and-sleep-apnea/. Accessed on July 20, 2025.
2. National Heart, Lung, and Blood Institute. Sleep Apnea. Last updated on January 09, 2025. Available at: https://www.nhlbi.nih.gov/health-topics/sleep-apnea. Accessed on July 20, 2025.
3. National Council on Aging (NCOA). Sleep Apnea in Older Adults: Diagnosis and Treatment Options. June 4, 2025. Available at: https://www.ncoa.org/article/sleep-apnea-in-older-adults-diagnosis-and-treatment-options/. Accessed on July 20, 2025.

AIRLIFT^™
AIRvance System
Apnea/Hypopnea Index (AHI)
Cautery-Assisted Palatal Stiffening Operation (CAPSO)
Coblation
Cryosa^™ System (Cryosa, Arden Hills, MN)
ENCORE Tongue Suspension System
Genioglossal (Genioglossus) Advancement
Laser-Assisted Uvulopalatopharyngoplasty (LAUP)
Obstructive Sleep Apnea
Palatal Implants
Pillar Implant
Radiofrequency Ablation of Palatal Tissues and the Base of Tongue
Radiofrequency Volumetric Tissue Reduction (RFVTR) of the soft palate and/or the base of the tongue
RF Thermal Ablation
Somnoplasty System
Transpalatal advancement pharyngoplasty
Uvulopalatopharyngoplasty

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.