Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: obstructive sleep apnea

Treatment: Reconstruction midface, endoscopically assisted surgical expansion (EASE)

The insurer denied coverage for Reconstruction midface, endoscopically assisted surgical expansion (EASE)

The denial is overturned

The patient is an adult female with midface deformity and nasal obstruction. The patient is in college and has severe sleep apnea. Continuous positive airway pressure (CPAP) was trialed without benefit. Symptoms include daytime fatigue. The examination revealed nasal aperture stenosis and maxillary malformation. The patient has previously had jaw surgery and still has symptoms. The request is for procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

Surgical expansion of the oropharyngeal airway via LeFort procedures has been standard of care for recalcitrant obstructive sleep apnea (OSA) cases for decades and the outcome is no different whether endoscopically assisted or not.  

Procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system has final approval from the appropriate regulatory bodies for this diagnosis.

Surgical expansion of the oropharyngeal airway via LeFort procedures has been standard of care for recalcitrant OSA cases for decades and the outcome is no different whether endoscopically assisted or not.  It has been widely used in both the oral maxillofacial and facial plastic/reconstructive fields.     

This patient is a good candidate for procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system.

She has failed management of her OSA with both CPAP and jaw advancement surgery and this is the next logical step in her treatment algorithm.     

The procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system is the best available treatment for this patient at this time.     
  
Risks of surgery are increased over CPAP but as this is not an effective treatment for her, the risks of untreated OSA outweigh surgical risks.     

Surgical expansion of the oropharyngeal airway via LeFort procedures has been standard of care for recalcitrant OSA cases for decades and the outcome is no different whether endoscopically assisted or not.  It has been widely used in both the oral maxillofacial and facial plastic/reconstructive fields. She has failed management of her OSA with both CPAP and jaw advancement surgery and this is the next logical step in her treatment algorithm. 

In summary, the denial of procedure code 21142-52 described as reconstruction midface, Lefort 1; 2 pieces, segment movement in any direction, without bone graft. (Reduced Services) and procedure code 20690, described as Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.