Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system)

The insurer denied coverage for procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system).

The denial is overturned.

The patient has a past medical history of chronic rhinitis and congestion, obstructive sleep apnea, asthma, and migraines.  The sleep study revealed an apnea-hypopnea index of 16.9.  The patient had 2% (percent) central sleep apneas. The body mass index was 28.3.  The patient was in the provider's office for an initial evaluation.  The patient did not tolerate continuous positive airway pressure (CPAP) well.  The examination was normal.  The nasal endoscopy revealed boggy nasal mucosa and edema, clear drainage bilaterally, and inferior turbinate hypertrophy bilaterally.  The patient underwent a drug-induced sleep endoscopy where it was noted the patient did not tolerate CPAP. There was evidence of complete palate obstruction. The endoscopy showed lateral pharyngeal closure in the hypopharynx and oropharynx.  There was a severe amount of base of tongue collapse during the sleep endoscopy - complete.  There was no evidence of laryngeal involvement. The request was received for Inspire.  

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome and has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for procedure. This is the best available treatment for this patient.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient as he has failed the gold standard treatment of CPAP.

The adverse risks are not increased over standard treatment/services. 

The American Academy of Otolaryngology-Head and Neck Surgery stated it considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Candidates for this therapy are selected based on appropriate polysomnographic testing, age, body mass index and objective upper airway evaluation.  

The current US (united states) Food and Drug Administration (FDA) eligibility criteria for upper airway stimulator implantation includes age of at least 22 years, an apnea-hypopnea index (AHI) of 15-65, a lack of central apnea and a favorable pattern of the palatal collapse during drug-induced sleep endoscopy.

Patients with obstructive sleep apnea, unable to tolerate CPAP, and with an elevated body mass index (BMI) can be successfully treated with upper airway stimulation therapy.

The patient has an apnea hypopnea index  (AHI) of 16.9.  The patient had 2% central sleep apneas (1 event), per the sleep study. He had a favorable pattern of palatal collapse during drug-induced sleep endoscopy, and he was unable to tolerate CPAP, the gold standard of care. Therefore, the patient is appropriate for procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system) for obstructive sleep apnea to be rendered at a date of service to be determined. 

The carrier's denial of procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system) for obstructive sleep apnea should be overturned.