Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: obstructive sleep apnea

Treatment: Reconstruction midface, endoscopically assisted surgical expansion (EASE)

The insurer denied coverage for Reconstruction midface, endoscopically assisted surgical expansion (EASE)

The denial is upheld

This case involves a patient with a subject of review for the coverage of procedure code 21142-52 (Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction [endoscopically assisted surgical expansion (EASE)]. The diagnosis of the patient is documented as obstructive sleep apnea (OSA).

The patient underwent a LeFort 1 procedure with a bilateral sagittal split osteotomy and genioplasty with asymmetric repositioning. A sleep study report revealed moderate obstructive sleep apnea (respiratory disturbance index [RDI] 27) and an oxygen (O2) nadir of 92%. The patient was seen with moderate obstructive sleep apnea (OSA). Due to continuous positive airway pressure (CPAP) intolerance, the patient had maxillomandibular advancement (MMA)/genioplasty. The patient remains symptomatic and has a nasal obstruction.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes for this patient. 

The requested procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system, does not have final approval from the appropriate regulatory bodies for this diagnosis. 

The patient is not a good candidate for procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system. 

The requested procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system is not the best available treatment for this patient at this time. 

For obstructive sleep apnea, all surgical treatments carry the risks associated with any surgical procedure: bleeding, infection, pain, and discomfort. No procedure is guaranteed to be 100% successful, and results may vary.

There is not enough preliminary data to recommend maxillary expansion as the main therapeutic approach to address nasal breathing. Regarding the impact of maxillary expansion on nasal function, the research is favorable. To establish more precise patient selection criteria, identify the best procedures, and show long-term efficacy in long-term follow-up studies, more high-quality research is required.

According to the Milliman Care Guidelines, Reconstruction procedure is needed for eye, head, or neck abnormalities; examples include cleft palate or lip, maxillofacial deformities, eye muscle palsy and congenital atresias, cysts, or sinus remnants.

The medical records provided for review do not support the service being requested. The scientific evidence in peer-reviewed literature does not support an improvement in health outcomes for this patient.

In summary, the denial of procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system and coverage for the requested service/treatment should be upheld. 

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.