Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Poor sleep hygiene, anxiety disorder. 
Treatment: Sleep center titration study. 

The insurer denied the sleep center titration study. The denial is upheld. 

The patient is a female. She has clinical history significant for anxiety disorder, conversion disorder, psychogenic nonepileptic seizures, poor sleep hygiene with excessive caffeine intake, chronic insomnia related to mental disorder. She was recommended a laboratory-based sleep study for the diagnosis of obstructive sleep apnea. 

Based on the clinical note there was no documentation of the patient's complaint of loud habitual snoring, presence of excessive daytime sleepiness, or witnessed apnea. There was also no recording of the BMI (body mass index) at that time. The patient reported excessive caffeine intake in the form of soda, poor sleep hygiene, and multiple awakenings at nighttime. The patient also takes multiple antipsychotic medications. 

Subsequently, the patient underwent a home-based sleep study. The BMI was 53.2.  The sleep study was suggestive of mild obstructive sleep apnea, with an AHI (apnea-hypopnea index) of 6.5/hour, associated with oxygen saturation of 67%. The patient's average oxygen saturation was 97% for up to 98% of the total record time. The patient spent only 2% of the total record time with oxygen saturation less than 90%, and 0% of the total recorded time with oxygen saturation less than 80%.  

The patient was subsequently prescribed AutoPap (automatic titrating positive airway pressure). She has been on the AutoPap (automatic titrating positive airway pressure) and has had a follow-up face-to-face with the treating provider.  Clinical notes after the follow-up consistently document that the patient has failed the CPAP (continuous positive airway pressure) due to poor tolerance.  The note indicates that the patient documents that the CPAP (continuous positive airway pressure) pressure is adequate and the mask fit is also adequate, but she has been noncompliant.  

The last CPAP (continuous positive airway pressure) compliance data document that the patient used the CPAP (continuous positive airway pressure) only 13 nights out of 17 nights.  Only 13% of the total time on the CPAP (continuous positive airway pressure) had been more than four hours.  The patient's overall AHI (apnea-hypopnea index) while on the CPAP (continuous positive airway pressure) was well-controlled, at 3.4/hour. The mean pressure was 4.2 cmH2O (centimeters of water). Peak average pressure was 5.1 cmH2O (centimeters of water).  Average time in large leak per day was 44 minutes and nine seconds.  Therefore, the data suggest that the patient has failed the CPAP (continuous positive airway pressure) due to poor compliance and tolerance.  The physician recommends a CPAP (continuous positive airway pressure) titration study in an attempt to see if that will improve her compliance.  

No, the sleep center titration study is not medically necessary.  

Based on the guidelines from the American Academy of Sleep Medicine and the standard of practice in United States, a laboratory-based CPAP (continuous positive airway pressure) titration study after a home-based sleep study or laboratory-based sleep study confirming the diagnosis of obstructive sleep apnea requires the documentation of the following: 
1) In the case of a laboratory-based sleep study: 
-Presence of significant comorbid medical conditions which would make a home-based sleep study a contraindication such as presence of severe congestive heart failure, recent MI (myocardial infarction) or stroke defined as within six weeks of the study, presence of pulmonary disease requiring oxygen, concern for obesity hypoventilation syndrome, central sleep apnea. 
Before the performance of the home-based sleep study, the clinical data reflect that this patient does not qualify for laboratory-based sleep study due to the absence of clinically significant comorbid medical condition, which would alter the ventilatory requirement.  Therefore, the sleep center titration study is not appropriate or necessary.  
2)	In the case of home-based sleep study: 
- During the home-based sleep study, if they document the presence of central sleep apnea as such as more than 25% of the total events are central sleep apnea, or 
- Patient has spent more than 30% of the total record time with oxygen saturation less than 90% or 
- Patient has spent more than 1% of the total record time with oxygen saturation less than 80% qualifying the patient for the diagnosis of nonobstructive idiopathic alveolar hypoventilation.  

Under the above two circumstances, a patient would qualify for a laboratory based CPAP (continuous positive airway pressure) titration rather than an auto CPAP (continuous positive airway pressure) titration.  

It should be noted that the highest pressure on the auto CPAP (continuous positive airway pressure) machine was 5.1 cmH2O (centimeters of water), which documents control of the sleep apnea, which is defined by overall AHI (apnea-hypopnea index) of less than five per hour. However, there has been adequate documentation provided by the treating provider that the patient has been noncompliant with the treatment.  Tolerance has not been a question, as the patient states that the pressure setting is adequate.  In addition, the pressure requirement has been minimum according to the auto CPAP (continuous positive airway pressure) data.  There has been no recording of the central sleep apnea.  Of note, in order to achieve optimum health benefit, more than 70% of the nights must be on the machine for more than four hours.  In the case under review, only 13% of the nights the patient has used the machine for more than four hours.  Therefore, performing a laboratory-based CPAP (continuous positive airway pressure) titration would not affect the patient's compliance and tolerance.  Therefore, performing a laboratory-based CPAP (continuous positive airway pressure) titration study is not medically necessary.