Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: severe obstructive sleep apnea (OSA) 

Treatment: CPT 64568-RT (incision for implantation of cranial nerve neurostimulator electrode array and pulse generator) and CPT 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator)

The insurer denied coverage for CPT 64568-RT (incision for implantation of cranial nerve neurostimulator electrode array and pulse generator) and CPT 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator). The denial is reversed. 

Reviewer#1

This patient is a male with a history of chronic obstructive pulmonary disease, diabetes, emphysema, and of severe obstructive sleep apnea (OSA).  The patient was obese as documented by his BMI of 34.01.  The patient experienced the effects of OSA with sleepiness during the day and difficulty sleeping at night.  The patient's Apnea-Hypopnea Index (AHI) was 49 events/hour.  The patient had a trial of continuous positive airway pressure (CPAP) but the patient became intolerant to CPAP use and it could not be used to treat his OSA. The patient underwent a drug-induced sleep endoscopy which found an evaluation of the Velo pharynx and demonstrated primary anterior posterior collapse of the soft palate to the posterior pharyngeal wall.  The patient was found to have moderate retrolingual and lateral wall collapse as well as collapse of the base of tongue and the retroepiglottic space.  There was mild oxygen desaturation during the examination.
Based on the review of the literature, the use of hypoglossal nerve stimulation as an effective intervention for obstructive sleep apnea has been widely documented. The effectiveness of hypoglossal nerve stimulation was compared to an ablative surgical procedure and found to result in lowering the Apnea-Hypopnea Index (AHI) of patients to < 5 events/hour.6

Based on the review of the medical record, the patient met the FDA criteria for the use of hypoglossal nerve stimulation. The patient's AHI was 49 events/hour, and the FDA range for the use of hypoglossal nerve stimulation is AHI of 15- 64 events/hour and the failure of CPAP use.l2 The use of hypoglossal nerve stimulation for the care of obstructive sleep apnea has been approved by several medical societies.l3.14 The scientific evidence in peer-reviewed literature strongly supports the result in AHI improvement using hypoglossal nerve stimulation for obstructive sleep apnea.10, 12-14. Incision for implantation of cranial nerve neurostimulator electrode array and pulse generator)  and CPT 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including  connection to pulse generator  has been approved twice by the Food and Drug Administration which is the appropriate regulatory agency. 11,12

Based on this review, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of CPT 64568-RT (incision for implantation of cranial nerve neurostimulator electrode array and pulse generator) and CPT 0466T (insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator) should be reversed.