Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea (OSA) 
Treatment: Hypoglossal nerve stimulation 
The insurer is denied coverage for hypoglossal nerve stimulation. 
The denial is reversed.  

The patient was then a male with a past medical history of obstructive sleep apnea (OSA) and hypertension. The provider noted that the patient's apnea-hypopnea index (AHI) was 23.1 and the patient had a body mass index (BMI) of 22.43. The patient had predominantly obstructive events as there were 2% central and mixed apnea events.  The patient was unable to tolerate continuous positive airway pressure (CPAP) as he found it uncomfortable. The patient reported taking it off at night and had tried different masks and machines without improvement. The patient reported very loud snoring and waking up frequently gasping for air. The patient also reported feeling very tired during the day. The patient's history was also significant for hypertension. On the patient's drug-induced sleep endoscopy, there was the absence of complete concentric collapse; the patient had anterior posterior collapse. 

Hypoglossal nerve stimulator therapy for the treatment of obstructive sleep apnea (OSA) has been in peer reviewed literature for over two decades. It is FDA approved procedure for the treatment of OSA. Selective upper airway stimulation (UAS) using an implanted hypoglossal nerve stimulator has become a widely available surgical management for obstructive sleep apnea recalcitrant to continuous positive airway pressure (CPAP) treatment or for those patients for whom CPAP is not an option. Clinical trials have shown that in carefully selected adult patients there are dramatic clinical improvements.  One study showed a 68% decrease in the apnea-hypopnea index (AHI) and 70% decrease in oxygen desaturation index. Another study showed that UAS lead to significantly improved sleepiness, quality of life, and respiratory outcomes at five years. 

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).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, body mass index (BMI) and objective upper airway evaluation measures are required for proper patient selection. The following criteria are standard of care indications for hypoglossal nerve stimulator therapy: 22 years of age or older; Have moderate to severe OSA (AHI range from 15-65 with <25% central apneas); Unable to use CPAP; Free of complete concentric collapse at the palate as seen on drug-induced sedation endoscopy. 

In this case, this was then a male who has obstructive sleep apnea (OSA) with Apnea-Hypopnea Index (AHI) of 23, and was unable to tolerate continuous positive airway pressure (CPAP) masks. The patient's drug-induced sleep endoscopy showed free of complete concentric collapse at the palate. This patient's body mass index (BMI) was 21.7. This patient met the clinical criteria for proper patient selection of the hypoglossal nerve stimulator therapy procedure. Sleep apnea, if left untreated has the potential for serious medical sequela.  This patient did not have any contraindication for hypoglossal nerve stimulation therapy. 

The hypoglossal nerve stimulation for obstructive sleep apnea (OSA) is likely to be more beneficial than nay of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for hypoglossal nerve stimulation (Inspire upper airway stimulation system) for obstructive sleep apnea (OSA) should be reversed.