Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system)

The insurer denied coverage for procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system).

The denial is overturned.

The patient has a history of obstructive sleep apnea. The medical history reveals an apnea hypopnea index (AHI) of 16.9 and a nasopharyngel examination that found:

"Endoscopic examination showed that he had nasal septal deviation with turbinate enlargement. There was evidence of palate obstruction in the AP [anterior-posterior] direction - complete. During sleep apnea there was also lateral pharyngeal closure in the hypopharynx and oropharynx. There was a severe amount of base of tongue AP closure during sleep endoscopy- complete. There was no evidence of laryngeal involvement."

Medical record documented his inability to tolerate continuous positive airway pressure (CPAP).

There is an extensive literature showing the efficacy of hypoglossal nerve stimulation and the treatment of obstructive sleep apnea. The use of hypoglossal nerve stimulation has been approved by international and national professional societies. The Food and Drug Administration (FDA) has twice approved the use of hypoglossal nerve stimulation for the effective  treatment of obstructive  sleep apnea. The patient fulfilled all of the FDA requirements for the uses of hypoglossal stimulation which included AHI of greater than or equal to 15 and less than or equal to 65, his was 16.9; who have been confirmed to fail or cannot tolerate positive airway pressure (CPAP), this has been documented; and who do not have a complete concentric collapse at the soft palate level, which was documented by the endoscopy.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

The procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system) for obstructive sleep apnea have final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system) for obstructive sleep apnea.

The procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system) for obstructive sleep apnea are best available treatment for this patient at this time.

The requested service for hypoglossal nerve stimulation for obstructive sleep apnea is more beneficial than any other standard procedure for this patient.

The adverse risks for the procedure of nerve stimulation are far less than the only other alternative which would be a tracheotomy which carries substantive risk for morbidity and mortality.

The denial should be reversed as the patient met all the requirements as noted in the two FDA approvals and by consensus of all the peer-reviewed literature

The carrier's denial of procedure codes - 64568 and 0466T (treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system) for obstructive sleep apnea should be overturned.