23 Miss. Code. R. 203-4.20 - Uvulopalatopharyngoplasty (UPPP/UP3)

Medicaid covers uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea syndrome if all of the following are present:

A. Documented obstructed sleep apnea (OSA) with apnea hypopnea index (AHI) or respiratory disturbance index (RDI) which meets the following parameters in a) or b) below:

1. UPPP/UP3 as sole procedure: with AHI/RDI greater than fifteen (15) and less than forty (40), or AHI/RDI ten (10) to fifteen (15) with one (1) or more of the conditions listed below:

a) Hypertension,

b) Cardiac arrhythmias predominately during sleep,

c) Pulmonary hypertension,

d) Documented ischemic heart disease,

e) Impaired cognition or mood disorders,

f) History of stroke, or

g) Excessive daytime sleepiness, as documented by either a score of greater than ten (10) on the Epworth Sleepiness Scale or inappropriate daytime napping such as during driving, conversation, or eating, or sleepiness that interferes with daily activities.

2. UPPP/UP3 as part of a planned staged or combined surgery aimed at also relieving retro lingual obstruction such as genioglossal advancement, hyoid myotomy and suspension: with AHI/RDI greater than fifteen (15), or AHI/RDI ten (10) to fifteen (15) with one (1) or more of the conditions listed below:

a) Hypertension,

b) Cardiac arrhythmias predominately during sleep,

c) Pulmonary hypertension,

d) Documented ischemic heart disease,

e) Impaired cognition or mood disorders,

f) History of stroke, or

g) Excessive daytime sleepiness, as documented by either a score of greater than ten (10) on the Epworth Sleepiness Scale or inappropriate daytime napping, (e.g., during driving, conversation, or eating) or sleepiness that interferes with daily activities.

B. Continuous positive airway pressure (CPAP) has been tried with well-supported follow-up and clearly failed or is not tolerated.

C. Pre-operative evaluation including fiber optic endoscopy suggest retro-palatal narrowing is the primary source of airway obstruction if UPPP/UP3 is the sole procedure or a combined surgery aimed at also relieving retro lingual obstruction.

Notes

23 Miss. Code. R. 203-4.20

Miss. Code Ann. § 43-13-121