Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T)

The insurer denied the Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T)

The denial was overturned.

This is a female patient with a diagnosis of obstructive sleep apnea. The patient presented for a consultation and evaluation of sleep.  There were reports of difficulty sleeping and loud snoring.  Nocturnal symptoms were reported.  The patient reported to be very tired during the day.  The patient was unable to utilize a CPAP machine as she found it uncomfortable.  The patient had also tried different masks and machines without improvement.  The patient reported that trigeminal neuralgia caused her to feel uncomfortable with the CPAP.  Spasms were reported every time she falls asleep.  There were reports of pain in the teeth and tongue when it was hit with air.  On examination, the hypopharynx and larynx were unable to be visualized. The patient underwent a drug-induced sleep endoscopy.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T) has the final approval from the appropriate regulatory bodies for this diagnosis. The patient is a good candidate for Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T). Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T) is the best available treatment for this patient at this time primarily because the patient does not tolerate using CPAP.

This patient presents with obstructive sleep apnea with an Apnea-Hypopnea Index of 37.2. She is unable to tolerate CPAP. The patient has also undergone a sleep endoscopy and the physician has confirmed she does not have complete concentric collapse of the upper airway. The patient meets the standard of care criteria for the implantation of a hypoglossal nerve stimulator. The proposed procedure has been denied because it has been deemed investigational. The American Academy of Otolaryngology-Head and Neck Surgery 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).  The hypoglossal nerve stimulator has been approved by the FDA since May 2014. In addition, The National Institute for Health and Care Excellence (NICE) did an extensive literature search looking at the efficacy of hypoglossal nerve stimulation implantation for obstructive sleep apnea. 

Due to the predominance of medical literature supporting the effectiveness of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea, this is likely to be more beneficial than any other standard health service.

The carrier's denial of Hypoglossal Nerve Stimulation or Inspire Upper Airway Stimulation System (procedure code 64565 and 0466T) should be overturned.