Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 12-year-old female with a history of sleep apnea. She has a prior history of tonsillectomy and adenoidectomy. She presented to her otolaryngologist with symptoms consistent with obstructive sleep apnea. A sleep study in September 2003 revealed a respiratory disturbance index (RDI) of 5.7 and lowest oxygen desaturation of 93%. This was interpreted at a sleep disorder clinic as mild obstructive sleep apnea. The patient was fitted with a BiPAP and had marked improvement in her symptomatology as documented by her otolaryngologist in May 2004. The patient had been compliant with BiPAP use. The patient then underwent spinal fusion surgery for severe scoliosis. The patients otolaryngologist has documented that the patient has become intolerant of CPAP/BiPAP. He has requested authorization for uvulopalatopharyngoplasty and partial glossectomy with radiofrequency. A complete sleep study obtained in November 2004 documents an RDI of 6.7 and lowest oxygen desaturation of 94%. Overall sleep efficiency was 89%. Only one central apnea event was noted and the remainder of events were all obstructive hypopneic events. RDI increased slightly during REM sleep to 7.6. This was interpreted as obstructive sleep apnea (hypopnea). Authorization for palate surgery was denied by the Health Plan on the basis that the patients records do not demonstrate the requested procedure is medically necessary. The Health Plan has recommended the alternative service of CPAP for treatment of the enrollees medical condition. Polysomnography is used to evaluate sleep disordered breathing. Adult diagnostic criteria for obstructive sleep apnea have been shown to be inapplicable in children. Numerous studies have been performed to help establish recommended limits for normal polysomnographic values in children and adolescents. Based upon current established guidelines, the patient meets criteria to support the diagnosis of mild to moderate obstructive sleep apnea. Tonsillectomy and adenoidectomy is the standard first line treatment for childhood obstructive sleep apnea syndrome. This surgery is helpful in relieving obstruction in the majority of children with adenotonsillar hypertrophy, but patients with severe disease may not be completely cured with this surgery. The patient has demonstrated persistent symptomatic obstructive sleep apnea despite this surgery. CPAP therapy was appropriately instituted. The success of CPAP therapy is dependent on patient compliance and can reach 100% success with regular nightly use. Failure to tolerate CPAP therapy is the single most common reason for cessation of medical therapy. Patients who are not capable of tolerating CPAP therapy must, therefore, seek surgical correction to alleviate the symptoms and sequela of this disease. The exact surgical procedures that are recommended must be individualized based on the patients clinical exam, fiberoptic nasopharyngoscopy, and the severity of the sleep apnea. Untreated childhood obstructive sleep apnea syndrome can result in pulmonary hypertension, systemic hypertension, growth failure, excessive daytime sleepiness, behavioral problems and impaired academic performance. The patient is 52 and weighs 110 pounds, with a BMI of 20. Physical exams report that this patient has a long redundant palate and very full base of tongue pushing her epiglottis posteriorly. The patients otolaryngologist has documented that the patient has become intolerant to CPAP/BiPAP. The patient did not have resolution of her obstruction with tonsillectomy and adenoidectomy. Further surgery is medically appropriate and indicated at this point and should be authorized. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.