Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Nerve treatment (procedure codes 64568 and 0466T).

The insurer denied coverage for nerve treatment (procedure codes 64568 and 0466T).
The denial is overturned.

This is a male patient who is recommended to obtain an implantable hypoglossal nerve stimulator for his documented severe obstructive sleep apnea (OSA) refractory to continuous positive airway pressure (CPAP) use. The patient has a body mass index (BMI) of 27.8. He has a contextual history of severe OSA, with a baseline apnea-hypopnea index (AHI) of 39 events per hour. The patient has a remote history of uvulopalatopharyngoplasty (UPPP) surgery. The patient has established compliance with CPAP with continued elevated Epworth scores and sleepiness. The patient has documented intolerance of CPAP. The patient's home sleep apnea test was notable for severe OSA by 4% criteria, overall AHI of 30 events per hour which is consistent with severe OSA.

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. The evidence is sufficient to determine the effects of the technology on health outcomes. Inspire (hypoglossal nerve stimulator) device holds a demonstrable pre-test probability of longitudinal benefit and efficacy as compared to standard surgical approaches for OSA. The role of nerve stimulation among surgical procedures for the treatment of OSA has been established. In this case, the patient is a reasonable candidate for the procedure based on his clinical history. The patient has documented severe OSA. The patient has tried multiple interventions including UPPP as well as trial of CPAP use. Despite compliance to CPAP use and attempts at habituation, the patient's symptoms and OSA were not responsive. To date, all interventions have been ineffectual in treating this patient's severe OSA. Cranial nerve implantation is the patient's last best clinical option to avoid sequelae from untreated obstructive severe sleep apnea. The patient is not obese with a body mass index of 27.8. There is no evidence of central sleep apnea. Given this patient's baseline degree of severe OSA, a cranial nerve stimulator is a viable treatment for this patient. If left untreated, the patient is at risk for complications associated with OSA, such as increased risk of death due to cardiovascular disease and accidents.

Based on the medical history provided for review, the patient is a reasonable candidate for cranial nerve stimulator implantation. The patient has no concentric collapse of his airway on drug induced sleep endoscopy. The patient is not obese. The patient has marked hypersomnia and is intolerant of CPAP use.

Based on the review of the medical record and literature, this patient is a good candidate for this requested procedure as he has no concentric collapse of his airway on drug induced sleep endoscopy, he is not obese, he has marked hypersomnia, and he is intolerant of CPAP. The patient is at risk for medical complications of his untreated severe OSA.                                                    
  
The requested service, nerve treatment (procedure codes 64568 and 0466T) is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for nerve treatment (procedure codes 64568 and 0466T) should be overturned.