Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Sleep problem (obstructive sleep apnea) (procedure codes 64582, L8680, L8588)
The insurer denied coverage for sleep problem (obstructive sleep apnea) (procedure codes 64582, L8680, L8588).
The denial is overturned.

This case involves a patient diagnosed with obstructive sleep apnea (OSA) who was being recommended for hypoglossal nerve stimulation. The patient was denied coverage for the procedure with claims that treatment can be approved at the planned clinical criteria when all the following are met to include that they are her test results with an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour and less than or equal to 65 events per hour, and no more than 25% (percent) of the patient's total AHI or RDI score central or mixed.  The patient must have a certain body weight with a body mass index of 32 or less, with complete concentric collapse at the soft palate level during drug-induced sleep endoscopy not present and documentation that other treatments to include continuous positive airway pressure (CPAP) have been tried and not effective. The information provided did not confirm a body mass index of 32 or less.  For this reason, the treatment option cannot be authorized.  

Records indicated that the patient was being seen for dysphonia, coughing, snoring, and sleep apnea. The patient reported snoring at night with pausing, gasping, and choking.  The patient underwent polysomnography showing an apnea hypopnea index (AHI) of 32.3 with central and mixed apneas less than 25% (percent) of the total apneas. The patient had a body mass index of 30.86 and had not yet tried a CPAP (continuous positive airway pressure) machine. The patient was diagnosed with Barrett's esophagus 5 to 6 years prior and was following gastroenterology with their most recent endoscopy at that time conducted 3 to 4 months prior. The patient was seen regarding obstructive sleep apnea. The patient's body mass index at that time was 34.2 and the patient had tried a CPAP machine without relief. The patient complained removing the mask during sleep and tried various types of masks without relief. The patient also reported that the masks were causing claustrophobia, skin irritation, difficulty breathing, and a dry mouth. Comorbidities included weight gain, daytime fatigue, and difficulty driving long distances due to fatigue. A video endoscopy showed thick obliteration of the vallecula, positive Mueller maneuver on inspiration, nasopharynx collapse on inspiration and apparent anterior to posterior (AP) direction, with larynx epiglottis and vocal cords normal. This review pertains to the denial of coverage for sleep problem (obstructive sleep apnea) (procedure codes 64582, L8680, L8588). 

Literature notes that hypoglossal nerve stimulation (HNS) is in widespread use for obstructive sleep apnea (OSA) treatment. It is a not anatomical modifying surgery able to achieve an adequate objective and subjective result with a reasonable complication rate.  Ideally, patients should have the assessment of OSA severity, BMI (body mass index) < (less than) 32, collapse pattern during drug-induced sleep endoscopy (DISE), and many other parameters, is central for a good patient selection and customization of OSA treatment. The patient in question was diagnosed with obstructive sleep apnea per polysomnography, failed to respond effectively to a trial with a CPAP device, had an AHI (apnea hypopnea index) of 32.3, and an elevated body mass index. 

Based on the above, the insurer's denial must be reversed. 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 sleep problem (obstructive sleep apnea) (procedure codes 64582, L8680, L8588) is substantiated.