CMS WISeR documentation checklist · §6.2.12
Operational Guide v7.0, last updated July 24, 2026 · retrieved 2026-09-14
Hypoglossal Nerve Stimulation (HGNS) for Obstructive Sleep Apnea (L38307, L38310, L38385)
CMS: “To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity of services. Subsections 6.2.1 to 6.2.13 list the documentation requirements for example services. For detailed documentation requirements, providers who choose to submit a prior authorization request for a WISeR Select Item or Service should refer to the relevant NCDs and/or their MAC jurisdiction’s LCDs and Local Coverage Articles (LCAs), if available, for guidance. They can be found on the Medicare Coverage Database website.”
General documentation requirements for the implantation of a hypoglossal nerve stimulator for obstructive sleep apnea are as follows — the following requirements should be met:
- Age 22 or older
- BMI is less than 35 kg/m2
- Results of polysomnography performed within 24 months of first consultation of HGNS implant (include date of first consultation of HGNS implant and date of polysomnography test) showing: a) Predominantly obstructive events (defined as central and mixed apneas less than 25% of the total apnea-hypopnea index [AHI]) AND b) AHI is 15 to 65 events per hour
- Documentation demonstrating one of the following: • Continuous positive airway pressure (CPAP) failure (defined as AHI greater than 15 events per hour, despite CPAP usage) OR • CPAP intolerance (defined as less than 4 hours per night, 5 nights per week, or CPAP has been returned), including shared decision-making that the patient was intolerant of CPAP despite consultation with a sleep expert
- Drug-induced sleep endoscopy (DISE) procedure showing absence of complete concentric collapse at the soft palate level
- Documentation of any other anatomical findings that would compromise performance of device, e.g., tonsil size 4 per standardized tonsillar hypertrophy grading scale, laryngeal abnormalities that would cause a fixed obstruction (e.g., supraglottic stenosis, post-radiation fibrosis, laryngoceles, anterior cervical osteophytes impinging or pushing on the posterior pharynx)
- Documentation of counseling regarding future MRI utilization (depending on model implanted)
- Assessment and documentation of none of the following contraindications: a) Central and mixed apneas compromising more than one-quarter of the total AHI b) Another implantable device that could result in an unintended interaction with the HGNS implant system (e.g., pacemakers, implantable cardioverter-defibrillators, other nerve stimulators) c) BMI equal to or greater than 35 kg/m2 d) Neuromuscular disease e) Hypoglossal-nerve palsy f) Severe restrictive or obstructive pulmonary disease g) Moderate-to-severe pulmonary arterial hypertension h) Severe valvular heart disease i) New York Heart Association class III or IV heart failure j) Recent myocardial infarction or severe cardiac arrhythmias (within the past 6 months) k) Persistent uncontrolled hypertension despite medication use l) An active, serious mental illness that reduces the ability to carry out Activities of Daily Living and would interfere with the patient’s ability to operate the HGNS device and report problems to the attending provider m) Coexisting non-respiratory sleep disorders that would confound functional sleep assessment n) Patient is or plans to become pregnant o) Patient is unable or does not have the necessary assistance to operate the sleep remote p) Patient has a condition or procedure that has compromised neurological control of the upper airway
- [20] Prior authorization and pre-payment medical review for HGNS will be implemented for the primary codes specified in Appendix A. As published in the MLN Connects® Newsletter on January 22, 2026, WISeR does not include CPT 64568 billed with ICD-10 code G47.33 (obstructive sleep apnea). Providers with questions about billing for HGNS should contact their respective MAC.