Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea. 
Treatment: E0562 (Heated humidifier with positive airway pressure) E0601 (PAP device). 

The insurer denied the E0562 (Heated humidifier with positive airway pressure) 
E0601 (PAP device). 

The denial is overturned. 

The patient is a male who was reported to have been diagnosed with obstructive sleep apnea. The patient's provider requested a positive airway pressure device (E0601 and E0562) for treatment of the patient's symptoms related to obstructive sleep apnea. The requested device was noted to have been previously denied as it was noted that the patient was previously approved of positive airway pressure device. There was no indication that the patient was compliant with treatment with the previously approved device. Additionally, there was no indication that the previously approved device had malfunctioned or was inoperable. However, subsequent clinical documentation provided indicates that the request was for extension of rental of the positive airway pressure device. 

Additional clinical information provided indicates that the patient was largely compliant with positive airway pressure therapy. A downloaded compliance report indicates that the patient was treated with auto titrating positive airway pressure (APAP) device for obstructive sleep apnea. The compliance report indicates that the patient had used the device for more than four hours per night on 87% of the nights (26 out of 30 days) for the period. The patient was noted to have had a residual apnea-hypopnea index of one per hour indicating good control of apneic events. 

The patient was noted to have been seen for a clinical encounter. He was noted to have been diagnosed with obstructive sleep apnea following two consecutive nights of type III portable sleep studies performed. The patient was noted to have had an overall apnea-hypopnea index (AHI) of 33 per hour with an oxygen saturation nadir of 73%. He was noted to have a medical history significant for persistent severe asthma, hypertension, chronic obstructive pulmonary disease, diabetes mellitus, diverticulitis, elevated liver enzymes and hypercholesterolemia. A pulmonary function test was noted to have indicated moderate ventilatory impairment in combination with obstructive and restrictive pattern. 

Yes, the proposed treatment (continued use of positive airway pressure device beyond the initial rental period of three months) is found to be medically necessary and appropriate for the patient. 

The patient is a male who was reported to have been diagnosed with obstructive sleep apnea. The patient's provider requested a positive airway pressure device (E0601 and E0562) for treatment of the patient's symptoms related to obstructive sleep apnea. He was noted to have been diagnosed with obstructive sleep apnea following two consecutive nights of type III portable sleep studies performed. The patient was noted to have had an overall apnea-hypopnea index (AHI) of 33 per hour with an oxygen saturation nadir of 73%. He was noted to have a medical history significant for persistent severe asthma, hypertension, chronic obstructive pulmonary disease, diabetes mellitus, diverticulitis, elevated liver enzymes and hypercholesterolemia. A pulmonary function test was noted to have indicated moderate ventilatory impairment in combination with obstructive and restrictive pattern. 

Clinical information reviewed indicates that the patient was largely compliant with positive airway pressure therapy. A downloaded compliance report indicates that the patient was treated with auto titrating positive airway pressure (APAP) device for obstructive sleep apnea. The compliance report indicates that the patient had used the device for more than four hours per night on 87% of the nights (26 out of 30 days) for the period between. The patient was noted to have had a residual apnea-hypopnea index of one per hour indicating good control of apneic events. He was noted to have been followed by the treating provider as indicated by clinical documentation.

Evidence in current peer-reviewed, evidence-based medical literature indicates that continued treatment with obstructive sleep positive airway pressure therapy for obstructive sleep apnea is clinically indicated in patients who are compliant with treatment and continued to receive benefit from the same. Therefore, based on current peer reviewed, evidence-based medical literature, the continued use of positive airway pressure device beyond the initial rental period of three months is found to be medically necessary and appropriate for this patient. 

The health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient during the initial denial for the positive a blood pressure device as there was lack of clinical documentation indicating the nature of the request and compliance with treatment. 

The health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient during the initial denial for the positive a blood pressure device as there was lack of clinical documentation indicating the nature of the request and compliance with treatment. However, subsequent clinical documentation provided indicates that the patient was largely compliant with positive airway pressure treatment and was being followed regularly by the treating provider.