Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Beginning March 1, 2022, prior authorization criteria will be effective for hypoglossal nerve stimulator (HNS) procedure code 64582 in Texas Medicaid.
Hypoglossal nerve stimulation involves the use of devices that deliver electrical pulses to the hypoglossal nerve by an implanted generator. HNS is a benefit of Texas Medicaid when medically necessary to treat obstructive sleep apnea (OSA) and seizures.
Prior Authorization Requirements
The surgical implantation of an HNS (procedure code 64582) and purchase of a device will be considered for prior authorization with documentation of the following criteria:
- Client has a documented diagnosis of OSA or seizures from a qualified health-care provider.
- For an OSA diagnosis, requests must include documentation that the client’s compliant use of continuous positive airway pressure (CPAP) for a minimum of 1 month (5 nights per week for at least 4 hours per night) has not been successful or cannot be tolerated.
- For an OSA diagnosis, complete concentric collapse at the soft palate level as seen in a drug-induced sleep endoscopy (DISE) procedure must be absent.
- The client is an appropriate surgical candidate so that implantation with anesthesia can occur.
The revision or removal of an HNS (procedure codes 64583 and 64584) does not require prior authorization.
For more information, call the TMHP Contact Center at 800-925-9126.