Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Moderate Obstructive Sleep Apnea
Treatment: Upper and Lower Jaw Surgery
The insurer denied the Upper and Lower Jaw Surgery
The denial is upheld.

The patient is a male. The case is a request to review the medical necessity for proposed orthognathic surgery / maxillomandibular advancement (MMA) surgery with genioglossus suspension  for an adult patient diagnosed with obstructive sleep apnea (OSA).

No, the Upper and Lower Jaw Surgery is not medically necessary.
The medical necessity of the proposed surgery has not been substantiated by the request. The case is a request to review the medical necessity of proposed orthognathic surgery / maxillomandibular advancement (MMA) surgery with genioglossus suspension for an adult patient diagnosed with obstructive sleep apnea (OSA). The patient is an adult male who is claimed to have obstructive sleep apnea. A sleep study noted apnea-hypopnea index (AHI) of 18. His Epworth Score is noted to be 22, and body mass index (BMI) is noted to be 25. He has a mild mandibular hypoplasia / malocclusion as well. He has no significant speech issues of any real functional consequence. His oral surgeon has proposed orthognathic surgery / maxillomandibular advancement (MMA) surgery with genioglossus suspension.

The clinical documentation does not support the level of obstruction noted in this patient, nasopharyngeal, oropharyngeal, or hypopharyngeal. There is an endoscopic evaluation, and documented complete nasal and oral examination, without a stated pharyngeal level of obstruction. Nasal obstruction is noted. Septoplasty and turbinoplasty / turbinectomy is suggested, but not documented to have been completed. There is documented history of an oral orthotic device. There is no mention of why continuous positive airway pressure (CPAP) is not effective or useful in this patient, and no documented continuous posiive airway pressure titration trial, or clinical notes indicating a reason for failure (claustrophobia, aerophagia, etc). There are no documented medical comorbidities. There are some clinical photographs and radiographs submitted.

In short, there is inadequate clinical diagnostic information submitted to meet a diagnostic standard of care to substantiate the request for surgery. The surgery is therefore denied as not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The case is a request to review the medical necessity of proposed orthognathic surgery / maxillomandibular advancement (MMA) surgery with genioglossus suspension for an adult patient. There is not adequate documentation to substantiate the medical necessity of the requested services. A defined level of obstruction in this request is evidenced to be to be nasal, based upon submitted notes. Nasal surgery is suggested, but has not yet been performed. There is no documented failed continuous positive airway (CPAP) / bi-level positive airway pressure (BiPAP) titration trial, and no medical information provided to illustrate any associated co-morbidities.  There is no documented intolerance of continuous positive airway pressure with demonstration of aerophagia, poor mask fit, or claustrophobia. The clinical detail fails to substantiate any medical necessity in this request.