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 or adenoidectomy.

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

• MED.00002 Multiple Sleep Latency Testing (MSLT) and other Sleep Testing Services;
• SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring;.
• CG-SURG-30 Tonsillectomy for Children.

Medically Necessary:

Uvulopalatopharyngoplasty (UPPP): 

Uvulopalatopharyngoplasty (UPPP) is considered medically necessary when ALL of the following criteria (1 – 4 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:
      • Hypertension; or
      • Cardiac arrhythmias predominately during sleep; or
      • Pulmonary hypertension; or
      • Documented ischemic heart disease; or
      • Impaired cognition or mood disorders; or
      • History of stroke; or
      • Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness Scale or inappropriate daytime napping, (e.g., 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:  
      • Hypertension; or
      • Cardiac arrhythmias predominately during sleep; or
      • Pulmonary hypertension; or
      • Documented ischemic heart disease; or
      • Impaired cognition or mood disorders; or
      • History of stroke; or
      • 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 any of the following:
   • Claustrophobia from CPAP; or
   • Inability to breathe through the nose; or
   • Pain or discomfort from CPAP; or
   • User intolerance to CPAP; or
   • Individuals at high pressures of CPAP (greater than 10 cm H₂O) complaining of pressure discomfort.
     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 three 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 (1-4 below) are met:

1. The treatment of OSA in the individual is medically necessary based on either a) or b) 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:
      • 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
      • Impaired cognition or mood disorders; or
      • Hypertension; or
      • Ischemic heart disease or history of stroke; or
      • Cardiac arrhythmias, or
      • Pulmonary hypertension.
        AND
2. The individual has failed treatment with CPAP as demonstrated by any of the following:
   • Claustrophobia from CPAP; or
   • Inability to breathe through the nose; or
   • Pain or discomfort from CPAP; or
   • User intolerance to CPAP; or
   • Individuals at high pressures of CPAP (greater than 10 cm H₂O) complaining of pressure discomfort.
     AND
3. There is 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 three consecutive months.

Jaw Realignment Surgery:

Jaw realignment surgery (that is, maxillomandibular advancement) is considered medically necessary when ALL of the following criteria (1-4 below) are met:

1. The treatment of OSA in the individual is medically necessary based on either a) or b) 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:
      • 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
      • Impaired cognition or mood disorders; or
      • Hypertension; or
      • Ischemic heart disease or history of stroke; or
      • Cardiac arrhythmias, or
      • Pulmonary hypertension.
        AND
2. The individual has failed treatment with CPAP as demonstrated by any of the following:
   • Claustrophobia from CPAP; or
   • Inability to breathe through the nose; or
   • Pain or discomfort from CPAP; or
   • User intolerance to CPAP; or
   • Individuals at high pressures of CPAP (greater than 10 cm H₂O) complaining of pressure discomfort.
     AND
3. The individual has failed surgical intervention with either UPPP or genioglossus advancement and/or hyoid myotomy with suspension or 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 three 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 as a sole procedure with AHI/RDI under 10 events per hour is considered not medically necessary.

Treatment of snoring without OSA is considered not medically necessary including, but not limited to the use of the following treatment methods:

1. UPPP; 
2. Radiofrequency Volumetric Tissue Reduction (RFVTR) of the soft palate and/or the base of the tongue, including Somnoplasty^® and Coblation;^®
3. Laser-Assisted Uvulopalatoplasty (LAUP);
4. Cautery Assisted Palatal Stiffening Operation (CAPSO) or Palatal Implants.

Investigational and Not Medically Necessary:

The use of palatal implants is considered investigational and not medically necessary including, but not limited to:

1. Injection snoreplasty;
2. The Pillar^TM system.

UPPP is considered investigational and not medically necessary for UARS (upper airway resistance syndrome).

Other surgical treatments for OSA are considered investigational and not medically necessary including, but not limited to, the following:

1. Cautery-assisted Palatal Stiffening Operation (CAPSO);
2. Laser-Assisted Uvulopalatoplasty (LAUP);
3. Radiofrequency Volumetric Tissue Reduction (RFVTR) of the soft palate and/or the base of the tongue including Somnoplasty^® and Coblation;^®
4. Nasal surgery; (See SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring for further information.)
5. Transpalatal advancement pharyngoplasty;
6. The Repose^® System (bone-anchored tongue base suspension system by permanent suture technique).

In 2009, a Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults was prepared by the Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) (Epstein, 2009).  According to the AASM (which was formerly known as the American Sleep Disorders Association), "This task force was assembled to produce a clinical guideline from a review of existing practice parameters and available literature. All existing evidence-based AASM practice parameters relevant to the evaluation and management of OSA in adults were incorporated into this guideline." The following are some excerpted comments from this AASM document:

• 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, (e.g., 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 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, and symptoms).
• Laser-assisted uvulopalatoplasty (LAUP) is not recommended for the treatment of obstructive sleep apnea (AASM, 2009).

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).  This review of the evidence found that the published literature was comprised primarily of case series, with few controlled trials and 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 uncommonly reported.  Outcomes following pharyngeal surgeries were less consistent, and adverse events were more commonly reported. 

The following is excerpted from the AASM practice parameters:

• 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;
• 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 (Aurora, 2010).

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.

There is also 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; Janson, 1997; 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.  In a retrospective chart review of 134 subjects having undergone UPPP alone, those whose preoperative AHI was greater than 40 failed to have a successful result, (defined as a 50% reduction in AHI with postoperative AHI less than 20) in 73.5% cases.  That is to say the success rate was only 26.5% (Friedman, 2005).

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.  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 (retrolingual) obstruction during sleep are thought to occur.

The use of jaw realignment surgery in persons 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.  This conservative approach is appropriate in all but the most extenuating circumstances involving severe maxillofacial malformations related to OSA.  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.

At this time, there is not adequate evidence in the medical literature demonstrating the efficacy of radiofrequency ablation techniques for the treatment of OSA.  Radiofrequency Volumetric Tissue Reduction (RFVTR) involving the base of the tongue and soft palate, including two procedures marketed as Somnoplasty^® and Coblation^® have been described in the medical literature.  One case series evaluating RFVTR reported on 18 subjects with OSA who had a sub-optimal response to a prior UPPP and had a documented tongue base obstruction.  The baseline mean AHI was 39.6/hour.  After the procedure, the AHI dropped to a mean level of 17.8.  However, at a mean follow-up of 28 months in 16 of these subjects, the AHI had increased to 28.7.  The hypopnea index had risen to 22.9 from pre- and post-treatment levels of 17.4 and 13.6 respectively, and the mean oxygen saturation nadir had fallen to 85.8% from a post-treatment value of 88.3%.  In a separate 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.  Another case series reported on a group of 20 subjects with a pretreatment AHI of 28/hour.  In 13 of the 20, the AHI dropped by 50%, which was considered a success.  In the remaining subjects, the index did not significantly improve; in one person the index dramatically deteriorated.  A recently published randomized trial, involving 90 subjects with mild to moderate OSA, used RFVTR of both tongue and palate in 30 with comparisons to groups receiving CPAP or sham radiofrequency treatment.  Very short-term results only were reported, and there was no significant reduction in either AHI or nocturnal oxygen desaturation in the RFVTR-treated group.  Studies with longer-term outcomes would be useful in evaluating the benefits of this procedure.

A prospective non-randomized trial using a cautery-assisted palatal stiffening operation (CAPSO) procedure for the treatment of excessive snoring in 206 consecutive subjects reported a "success" rate of 92% initially, falling to 77% at one year.  Of note is the fact that the subjects with features suggestive of OSA or with evidence of OSA on sleep studies were excluded from the trial.  A small study involving 25 subjects with OSA reported a 40% success rate in terms of a reduction in AHI of 50% or more reaching to less than 10.  The mean AHI improved from 25.1 to 16.6.  There was no significant improvement in nocturnal oxygen desaturation, and the follow-up period was only 3 months.

LAUP has primarily been researched as a treatment of snoring without associated clinically significant OSA.  Thus, outcomes studies have focused on the elimination of snoring and not on pre- and post-procedure AHI.  In one study of 22 subjects with mild OSA, pre- and post-PSG were performed, along with assessments of daytime sleepiness.  Subjects with an AHI of greater than 15/hour were specifically excluded from the trial.  After a mean number of three treatments, the AHI was not significantly different from baseline.  The degree of excessive daytime sleepiness, as measured by the Epworth Sleepiness scale, improved from 8.5 to 5.2.  It should be noted that a value of 10 or below is considered normal.  Practice Parameters for the use of LAUP updated in 2000 by the Standards of Practice Committee of the AASM do not recommend LAUP for the treatment of sleep-related breathing disorders (Littner, 2001).  As referenced earlier in this document, in 2009, the AASM issued another document, the AASM Clinical Guidelines for the Evaluation, Management, and Long-term Care of OSA in Adults, in which they restated their position not to recommend LAUP (Epstein, 2009).

An updated search of the published literature noted that Franklin conducted a systematic review to evaluate the efficacy and adverse effects of surgery for snoring and OSA.  The review included four randomized controlled trials of surgery vs. either sham surgery or conservative treatment in adults and described outcome measures for daytime sleepiness, quality of life, AHI, and snoring.  Results of this review found that there was no significant effect on daytime sleepiness and quality of life following LAUP or RFVTR.  The authors concluded that these studies did not provide any evidence of effect from LAUP or RFVTR on daytime sleepiness, apnea reduction, quality of life or snoring (Franklin, 2009).

Two newer treatment methods proposed for OSA are the Repose^® bone-anchored suspension system (Influence Corp; San Francisco, CA), and injection snoreplasty.  Currently, the available literature on these procedures is limited to a half dozen case series studies.  Neither of these treatments has been evaluated long-term, and the numbers of subjects studied is very small.  At this time, there is insufficient evidence to make any recommendation about the appropriate clinical use of either the Repose^® system or injection snoreplasty.

To date, the literature has been limited regarding the safety and efficacy of the Pillar^TM palatal implant system for treating OSA.  Friedman reported a single institution, randomized controlled trial, involving 62 subjects with mild to moderate OSA who were selected based on "Friedman tongue position," soft palate size, and BMI less than 32.  Only 29 participants actually received the palatal implant and follow-up analysis.  Twenty-six participants underwent a "sham" procedure and analysis as the placebo group.  Follow-up was performed at three 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, four (4) of the 13 "successes" already had a pre-procedure AHI of less than 20, as did nine (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 quality of life (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 (Friedman, 2008).

Walker reported follow-up at approximately 15 months for 22 subjects out of an original 53 undergoing the Pillar palatal implant procedure for mild to moderate OSA at four sites in the U.S.  Of these 22, 13 had experienced a mean decrease in AHI from 19.5 to 13 at 90 days post implant (an AHI of 13 represents mild OSA by AASM definition).  Ten of these 13 (76.9%) maintained a mean AHI of 12.8 (persistent mild OSA) at approximately 15 months post-procedure.  There was some concern about the finding that 9/22 subjects, who had not improved 90 days post-procedure, experienced an increase in mean AHI from 19.9 pre-procedure to 28.4 at 90 days post-procedure and 26.2 at extended follow-up.  Whether this early and sustained deterioration was related to the failed implant procedure or to the natural history of OSA is unclear.  As with the Friedman study, no individual data were reported, and no information was provided as to whether any participants had their OSA totally relieved by the implant procedure.  Limitations of this case series study include the small sample size, lack of placebo control group, and the significant number of the original 53 subjects who were lost to follow-up which affected the generalizability of the results (Walker, 2007).

In summary, available studies, to date, do not provide convincing evidence of the long-term efficacy of palatal implants for persons with OSA.  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.

Another new technique that has been proposed as a surgical alternative for the treatment of OSA is transpalatal advancement pharyngoplasty (TAP).  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.  However, to date, there is very little published outcomes data for persons with OSA.  One retrospective review described 30 subjects who underwent a TAP procedure; twenty of these study subjects also had various tongue-base procedures performed at the same time as TAP.  Only ten had TAP alone.  The results of post-operative 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) (Woodson, 2005).  Larger studies are needed to establish the safety/efficacy of the TAP procedure, together with prospective comparisons with established palate-based surgical techniques.

In children, both the clinical presentation and criteria for the diagnosis of OSA differ from those in adults.  Therefore, adult criteria for diagnosis and treatment cannot be applied to the pediatric population.  Although PSG is required for the diagnosis of OSA in children, it has not been well standardized in its performance or interpretation.  The International Classification of Sleep Disorders, Second Edition Guidelines for the Diagnosis of Pediatric OSA, require an AHI of at least one (1) scorable respiratory event lasting at least two (2) respiratory cycles (Hoban, 2007).  However, Schechter (2002), reporting for the American Academy of Pediatrics (AAP) notes that, while this value of one (1) is of statistical significance based on normative data, it is unclear what level of AHI is of clinical significance or is associated with the development of adverse health outcomes.

OSA occurs most commonly in preschool aged children when the tonsils and adenoids are the largest, in relation to the airway size.  For this reason, adenotonsillectomy (AT) is generally recognized as the most appropriate first-line treatment of choice for childhood OSA (Benninger, 2007; Darrow, 2007; Hoban, 2007; Marcus, 2006; Schechter, 2002).  Success rates for AT in relieving OSA have been reported to be in the 75%-85% range, although lower rates have been reported in other studies, and Tauman (2006) reported a reduction in AHI to one (1) or less (i.e., complete resolution of OSA) in only 25% of 110 children, with obesity being associated with the lesser rates of success.  For children whose OSA has failed to resolve following AT, or who have a condition not amenable to AT (e.g., craniofacial anomaly as the primary underlying cause of OSA), or where AT is contraindicated, CPAP has been shown to be effective therapy with success rates in the 74%-97% range (Hoban, 2007).  However, as reported in a small study of 29 individuals (Marcus, 2006), adherence to CPAP therapy may be suboptimal in the pediatric age group.  Children with persistent OSA may require surgical treatment beyond AT including nasal airway reconstruction or maxillofacial surgery to expand the upper airway but published evidence is limited regarding the long term clinical benefit of surgical procedures other than AT in the pediatric population (Hoban, 2007; Shott, 2011). 

Description of Sleep Apnea

According to the American Academy of Family Physicians (AAFP), OSA syndrome affects over 18 million people in the United States.  However, many of these people have never had a proper diagnosis.  OSA is characterized by an interruption of breathing during sleep, due to extra or loose tissue in the upper airway that collapses into the air passage with the effort of inhalation.  This 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.

Description of OSA Treatments

UPPP is a surgical procedure involving the removal of excessive tissue in the upper airway, including tonsils and uvula, to widen the area to increase airflow.  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.

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.

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 jaw bone 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.  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. 

Another new method recently proposed for the treatment of OSA is 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 Repose System, the ENCORE^™ Tongue Suspension System (Siesta Medical, Inc., Los Gatos, CA), 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^TM 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^TM system received market clearance from the U.S. Food & Drug Administration in 2003.

Proposed Benefits

The goal of all sleep disorder diagnostic procedures is to correctly identify a specific sleep disorder(s), in order to render proper treatment(s).  Such treatment may alleviate sleep disorder symptoms and/or causes and allow the individual to achieve healthy sleep patterns.

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):  A measure that is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of two hours of sleep recorded by PSG using actual recorded hours of sleep, (i.e., the AHI may not be extrapolated or projected). For the purposes of this document, the terms apnea hypopnea index (AHI) and respiratory disturbance index (RDI) are interchangeable, although they may differ slightly in clinical use.  In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value.  These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.

Central sleep apnea (CSA):  A condition that is 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):  The most common treatment for OSA in adults which involves use of a mask during sleep over the nose that is attached to an air compressor that forces air through the nasal passages, opening the back of the throat.  In OSA, tissues in the upper airway, including the tongue, soft palate and nasal passages sag and block the airway.  The pressurized air in CPAP forces the tissues in the upper airway out of the way, allowing normal breathing to occur during sleep.  Variations of the CPAP device, including auto-CPAP and BiPAP^®_, adjust the airflow to the needs of the individual.  Some side effects that may occur with these devices include discomfort, nasal irritation and drying, facial skin irritation, abdominal bloating, mask leaks, sore eyes, and headaches.

Obstructive sleep apnea (OSA):  The interruption of breathing during sleep due to obstructive tissue in the upper airway that collapses into the air passage with respiration.  This may occur several hundred times a night and is thought to cause many symptoms, such as depression, irritability, sexual dysfunction, learning and memory difficulties and the frequent complaint of excessive daytime sleepiness.  An AHI/RDI greater than 30 events per hour is consistent with severe OSA. 

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  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.

When services may be Medically Necessary when criteria are met:

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

When services are also 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 Investigational and Not Medically Necessary:

When services are also Investigational and Not Medically Necessary:

Peer Reviewed Publications:

1. 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.
2. 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.
3. Benninger M, Walner D.  Obstructive sleep-disordered breathing in children. Clin Cornerstone. 2007; 9 Suppl 1:S6-12.
4. Black JE, Guilleminault C, Colrain IM, Carrillo O.  Upper airway resistance syndrome. Central electroencephalographic power and changes in breathing effort. Am J Respir Crit Care Med. 2000; 162(2 Pt 1):406-411.
5. Blumen MB, Dahan S, Fleury B, et al. Radiofrequency ablation for the treatment of mild to moderate obstructive sleep apnea. Laryngoscope. 2002; 112(11):2086-2092.
6. 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.
7. Brietzke SE, Mair EA. Injection snoreplasty: extended follow-up and new objective data. Otolaryngol Head Neck Surg. 2003; 128(5):605-615.
8. Cho LD, Kushida Ca, Guilleminault C, et al.  Upper airway resistance syndrome: sleep stage thresholds for esophageal-pressure-related arousals.  Sleep Research. 1997; 26:344. 
9. Conradt R, Hochban W, Brandenburg U, et. al. Long-term follow up after surgical treatment of obstructive apnea by maxillomandibular advancement.  Eur Resp J. 1997; 10(1):123-128.
10. Darrow DH. Surgery for pediatric sleep apnea. Otolaryngol Clin North Am. 2007; 40(4):855-875.
11. 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.
12. 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.
13. 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.
14. Exar EN, Collop NA. The upper airway resistance syndrome. Chest. 1999; 115(4):1127-1139.
15. 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.
16. 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.
17. 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.
18. 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.
19. 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.
20. 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.
21. 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.
22. 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.
23. 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.
24. 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.
25. Guilleminault C, Lee JH, Chan A.  Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med. 2005; 159(8):775-785.
26. 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.
27. 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.
28. Janson C, Gislason T, Bengtsson H, et al. Long-term follow-up of patients with obstructive sleep apnea treated with uvulopalatopharyngoplasty. Arch Otolaryngol Head Neck Surgery. 1997; 123(3):257-262.
29. 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.
30. Li KK, et al. Temperature-controlled radiofrequency tongue base reduction for sleep-disordered breathing; long term outcomes. Otolaryngol Head Neck Surg. 2002; 127(3):230-234.
31. Li KK. Surgical management of obstructive sleep apnea. Clin Chest Med. 2003: 24(2):365-370.
32. Mair, EA, Day RH.  Cautery-assisted palatal stiffening operation.  Otolaryngol Head Neck Surg. 2000; 122(4):547-556.
33. 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.
34. 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.
35. 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.
36. 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.
37. 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.
38. 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.
39. Nelson LM. Combined temperature-controlled radiofrequency tongue reduction and UPPP in apnea surgery. Ear Nose Throat J. 2001; 80(9):640-644.
40. 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.
41. 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.
42. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep disordered breathing and hypertension. N Engl J Med. 2000; 342(19):1378-1384.
43. Powell NB, Riley RW, Guillemault C. Radiofrequency tongue base reduction in sleep-disordered breathing: a pilot study. Otolaryngol Head Neck Surg. 1999; 120(5):656-664.
44. Powell NB, Riley RW, Troell RJ, et al. Radiofrequency volumetric tissue reduction of the palate in subjects with sleep-disordered breathing. Chest. 1998; 113(5):1163-1174.
45. Qureshi A, Ballard RD. Obstructive sleep apnea. J Allergy Clin Immunol. 2003; 112(4):643-651.
46. 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.
47. 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.
48. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996; 19(2):156-177.
49. Sher AE. Upper airway surgery for obstructive sleep apnea. Sleep Med. Rev. 2002; 6(3):195-212.
50. Shott SR.  Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy. Curr Opin Otolaryngol Head Neck Surg. 2011 Nov 2. [Epub ahead of print]
51. Silverberg D, Iaina A.  Treating obstructive sleep apnea improves essential hypertension and quality of life. Am Fam Phys. 2002; 65(2):229-236.
52. Steward DL. Effectiveness of multilevel (tongue and palate) radiofrequency tissue ablation for patients with obstructive sleep apnea syndrome. Laryngoscope. 2004a; 114(12):2073-2084.
53. 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.
54. 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.
55. Strollo PJ. Indications for treatment of obstructive sleep apnea in adults. Clin Chest Med. 2003; 24(2):307-313.
56. 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.
57. 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.
58. Terris DJ, Kunda LD, Gonella MC. Minimally invasive tongue base surgery for obstructive sleep apnea. J Laryngol Otol. 2002; 116(9):716-721.
59. 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.
60. 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.
61. Troell RJ. Radiofrequency techniques in the treatment of sleep-disordered breathing. Otolaryngol Clin North Am. 2003; 36(3):473-493.
62. 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.
63. 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.
64. 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. 
65. 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.
66. 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.
67. Wilhelmsson B, Tegelberg A, Walker-Enstrom ML, et al. A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnea. Acta Otolaryngol. 1999; 119(4):503-509.
68. Woodson BT. Transpalatal advancement pharyngoplasty. Oper Tech Otolaryn. 2007; 18(1):11-16.
69. 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.
70. 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.
71. Woodson BT, Robinson S, Lim HJ. Transpalatal advancement pharyngoplasty outcomes compared with uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 2005; 133(2):211-217.
72. 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.
73. 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.
74. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004; 291(16):2013-2016.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Sleep Medicine (AASM). Practice parameters for the treatment of obstructive sleep apnea in adults: the efficacy of surgical modifications of the upper airway. Report of the American Sleep Disorders Association. Sleep. 1996; 19(2):152-155.
2. American Academy of Otolaryngology Head and Neck Surgery. Surgical Management of Obstructive Sleep Apnea. 1998. Available online at: http://www.entnet.org/Practice/policySurgicalMgmtApnea.cfm.  Accessed on October 11, 2012. 
3. 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. 2010; 33(10):1408-1413.  Available at:  http://www.aasmnet.org/Resources/PracticeParameters/PP_SurgicalModificationsOSA.pdf.  Accessed on October 11, 2012.
4. Balk EM, Moorthy D, Obadan NO, et al.  Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32. (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-100551). AHRQ Publication No. 11-EHC052-EF. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ).  July 2011. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.  Accessed on October 10, 2012.
5. Blue Cross and Blue Shield Association. Radio-frequency volumetric tissue reduction for sleep-related breathing disorders. TEC Assessment, 2000; 13(15).
6. Blue Cross and Blue Shield Association. Surgical procedure for the treatment of obstructive apnea syndrome. TEC Assessment, 1996; 10(31).
7. Canadian Agency for Drugs and Technologies in Health (CADTH). Obstructive sleep apnea: A palatable treatment option? Issues in Emerging health Technologies, Issue 97. Ottawa, ON: CADTH; January 2007. Available at: http://www.cadth.ca/media/pdf/E0008_obstructive-sleep-apnea_cetap_e.pdf.  Accessed on October 11, 2012.
8. 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.
9. Centers for Medicare and Medicaid Services. National Coverage Determination for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA). NCD #240.4. Effective March 13, 2008.  Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&NCAId=19&NcaName=Continuous+Positive+Airway+Pressure+(CPAP)+Therapy+for+Obstructive+Sleep+Apnea+(OSA)&IsPopup=y&bc=AAAAAAAAAgAA&. Accessed on October 11, 2012.
10. Centers for Medicare and Medicaid Services. National Coverage Determination for Laser Procedures. NCD #140.5.  Effective May 1, 1997. Available at:  http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=69&ncdver=1&bc=AgAAQAAAAAAA&.  Accessed on October 11, 2012.
11. 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.  Available at:  http://www.aasmnet.org/Resources/ClinicalGuidelines/OSA_Adults.pdf.  Accessed on October 11, 2012.
12. Littner M, Kushida CA, Hartse K, et al. Practice Parameters for the use of laser-assisted uvulopalatoplasty: an update for 2000 (AASM). Sleep. 2001; 24(5):603-619.  Available at:  http://www.aasmnet.org/Resources/PracticeParameters/PP_Uvulopalatoplasty.pdf.  Accessed on October 11, 2012.
13. Mundy L, Sullivan T, Merlin T, et al. Horizon Scanning Unit, Adelaide Health Technology Assessment, University of Adelaide. The Pillar procedure: For the treatment of obstructive sleep apnoea and snoring. Horizon Scanning Report. Canberra, ACT: HealthPACT Secretariat, Department of Health and Ageing, Australian Government; September 2006. Available at: http://www.horizonscanning.gov.au/internet/horizon/publishing.nsf/Content/58685F8B48CC9EE7CA2575AD0080F340/$File/Pillar%20Procedure%20September2006.pdf.  Accessed on October 11, 2012.
14. National Institute for Clinical Excellence (NICE). Radiofrequency ablation of the soft palate for snoring. Interventional Procedure Guidance No.124. London, UK: NICE; May 2005. Available at: http://www.nice.org.uk/nicemedia/pdf/ip/IPG124guidance.pdf.  Accessed on October 11, 2012.
15. National Institute for Health and Clinical Excellence (NICE). Soft palate implants for obstructive sleep apnoea syndrome. Interventional Procedure Guidance 241. London, UK: NICE; November 2007. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG241Guidance.pdf.  Accessed on October 11, 2012.
16. National Institute for Health and Clinical Excellence (NICE). Soft palate implants for simple snoring. Interventional Procedure Guidance 240. London, UK: NICE; November 2007. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG240QRG.pdf.  Accessed on October 11, 2012.
17. 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. Available at: http://www.ers-education.org/media/2011/pdf/156487.pdf.  Accessed on October 11, 2012.
18. Schechter MS, American Academy of Pediatrics (AAP) Section on Pediatric Pulmonology Subcommittee on Obstructive Sleep Apnea Syndrome.  Technical Report:  Diagnosis and management of childhood obstructive sleep apnea syndrome.  Pediatrics. 2002; 109(4):1-20.
19. 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.
20. Sundaram S, Bridgman SA, Lim J, Lasserson TJ.  Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev. 2005;(4):CD001004.
21. U.S. Food and Drug Administration (FDA) Center for Devices and Radiologic Health (CDRH) 510(k) Premarket Notification Database. 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.  Accessed on October 11, 2012.
22. U.S. Food and Drug Administration (FDA) Center for Devices and Radiologic Health (CDRH) 510 (k) Premarket Notification Database.  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.  Accessed on October 10, 2012.

Apnea/Hypopnea Index (AHI)
Cautery-Assisted Palatal Stiffening Operation (CAPSO)
Coblation^®
ENCORE^™ Tongue Suspension System
Genioglossal (Genioglossus) Advancement
Laser-Assisted Uvulopalatopharyngoplasty (LAUP)
Obstructive Sleep Apnea
Pillar Implant
Radiofrequency Ablation of Palatal Tissues and the Base of Tongue
RF Thermal Ablation
Somnoplasty System^™ 
Thornton Adjustable Positioner (TAP)
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.