UnitedHealthcare, one of nation’s leading health plans, will provide coverage for Inspire, Inc.’s novel obstructive sleep apnea (OSA) therapy starting in August. This determination comes almost one year to the day after Aetna agreed to cover Inspire’s neurostimulation device. And over the past year, BlueCross BlueShield joined the movement and is now offering several plans that cover Inspire’s upper airway stimulation therapy.
UnitedHealthcare’s new policy considers Inspire’s FDA-approved neurostimulation device medically necessary for the treatment of moderate to severe OSA when certain criteria are met.
Background on OSA
Sleep disorders, including sleep apnea, pose a significant health risk. An estimated 30 million Americans suffer from obstructive sleep apnea, a disease that not only diminishes the quality of life, but also life expectancy. In OSA, patients’ throat muscles intermittently relax, blocking their airway during sleep, often causing them to snore.
OSA is the most common type of sleep apnea. Alarmingly, 80 percent of the cases of moderate and severe OSA remain unidentified, according to the American Sleep Apnea Association. This disease, if left untreated, can lead to cardiovascular problems such as hypertension, heart failure, atrial fibrillation, and stroke. Patients with OSA often benefit from positive airway pressure. Treatment involves a machine that delivers air pressure via nasal cannula or a mask placed over the nose and mouth while sleeping. Unfortunately, issues including comfort and ease of use lead to high rates of nonadherence. Poor compliance further adds to the appeal of Inspire’s ground-breaking technology.
The practice parameters published by the American Academy of Sleep Medicine (AASM) consider continuous positive airway pressure (CPAP) both first-line and gold-standard treatment for OSA. However, CPAP adherence has remained persistently low over the past 20 years, despite patient coaching and behavior modification. This low adherence rate is not only problematic but calls into question the use of CPAP as gold-standard therapy for OSA.
Inspire therapy is a small, remote-controlled, fully implanted system that senses breathing patterns and delivers mild stimulation to the hypoglossal nerve to maintain airway patency. The technology consists of a breathing sensing lead, a neurostimulator, and a pressure sensing lead. The FDA granted premarket approval in 2014.
The addition of UnitedHealth brings the total number of Inspire therapy coverage policies to 35, adding roughly 41 million members. As a result, approximately 125 million members now have coverage for this OSA treatment compared to 3 million members covered one year ago.
Coding Chest Wall Respiratory Sensor Procedures
The 2018 CPT® Category III code set contains three codes (0466T, 0467T, 0468T) for reporting insertion, revision
or replacement, and removal of a chest wall respiratory sensor electrode or electrode array.
- 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator
- List separately in addition to code for primary procedure
- Use 0466T in conjunction with 64568
- 0467T Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator
- Do not report 0467T in conjunction with 0466T, 0468T
- For revision or replacement of cranial nerve [eg, vagus nerve] neurostimulator electrode array, including connection to existing pulse generator, use 64569
- 0468T Removal of chest wall respiratory sensor electrode or electrode array
- Do not report 0468T in conjunction with (0466T, 0467T)
- For removal of cranial nerve [eg, vagus nerve] neurostimulator electrode array and pulse generator, use 64570
Stacy Chaplain, MD, CPC, is an executive editor at AAPC. Prior to her work at AAPC, she worked as Director of Clinical Coding Quality and has more than 4 years experience in medical writing & editing. Stacy received her Bachelor of Arts in Biology from The University of Texas at Austin and her Medical Doctorate from The University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Oregon local chapter.