Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea. 
Treatment: Code 64582, open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array. 
The insurer denied coverage for code 64582, open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array. 
The denial is overturned. 
 
This case involves an adult with a history of obstructive sleep apnea, snoring, obesity, nasal congestion, dyspnea on exertion, deviated nasal septum, and acute bacterial sinusitis. The patient presented for an evaluation related to recurrent sinusitis and deviated nasal septum with obstructive sleep apnea. Prior sleep study was consistent with moderate obstructive sleep apnea. It was indicated that the patient was unable to tolerate continuous positive airway pressure as it resulted in clogged left ear, nasal congestion, and discharge. Computed tomography scan showed inflammation in the patient's sinuses, polypoid disease tissue blocking the midportion of the nasal cavity, and drainage pathway. Endoscopy was consistent with purulent discharge. The patient's body mass index was documented as 33.23. There was a plan for surgical intervention with treatment of Augmentin prior to surgery. 

Reconsideration for the patient's 64582, open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array was requested to treat the patient's obstructive sleep apnea. The patient stated that they met Food and Drug Administration approved criteria for the requested procedure. 

The insurer stated that the request for 64582, open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array was denied. The request was denied as the patient's sleep apnea was not severe enough to qualify for the surgical intervention requested. 

It was stated that the request for 64582, open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array was denied. The documentation did not support that the patient had tried continuous positive airway pressure (CPAP) for 3 months with different masks to ascertain if the continuous positive airway pressure (CPAP) could not be used effectively. 

Per the cited references, hypoglossal nerve stimulation implant is recommended for the treatment of moderate to severe obstructive sleep apnea when the patient's body mass index is less than 35, when the patient has predominantly obstructive events defined as central and mixed apneas less than 25% of the total apnea hypopnea index, when the apnea-hypopnea index is 15-65 events per hour, and there is documentation of CPAP failure or CPAP intolerance. In this case, the patient's sleep study revealed apnea hypopnea index of 16 per hour. The apnea hypopnea index was in the moderate range. The disordered breathing events were comprised of hypopneas and were associated with mild to moderate decrease in oxygen saturation. The patient central mixed apneas were less than 25% of the total apnea hypopnea index. The apnea-hypopnea index was between 15-65 events per hour. 

There was documentation of CPAP intolerance. Thus, proceeding with the request is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for code 64582, open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array is substantiated.