Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Obstructive Sleep Apnea
Treatment: Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator
The insurer denied coverage for Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator.
The denial is overturned.

The patient has the medical diagnosis of moderate to severe obstructive sleep apnea (OSA). The patient has been seen and treated for OSA, gastroesophageal reflux disease, kidney stones, and medullary sponge kidney. The patient was diagnosed with severe OSA based on sleep study. The patient had an AHI (Apnea-Hypopnea Index) of 66 and no evidence of central sleep apnea. The patient has a normal body mass index (BMI) of 31. The patient has tried multiple masks both full face and nasal in order to use his continuous positive airway pressure (CPAP) machine, but is not tolerant to them, and cannot wear them for more than 2 hours at night. A sleep endoscopy was performed showing no concentric collapse. All of these factors make him a good candidate for the upper airway stimulator. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Outpatient surgery, 64582 x 1, hypoglossal nerve stimulator needs to have final approval from the appropriate regulatory bodies for this diagnosis.

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection. CPAP is the gold standard first line but for patients who cannot tolerate CPAP and fit the inclusion criteria, the upper airway stimulator is the second line treatment. This patient meets the criteria for the UAS device to treat his severe OSA.

This patient is a good candidate for outpatient surgery, 64582 x 1, hypoglossal nerve stimulator. Outpatient surgery, 64582 x 1, hypoglossal nerve stimulator is the best available treatment for this patient at this time.

The upper airway stimulator was FDA (Food and Drug Administration) approved and due to its success, the inclusion criteria were expanded years later, to include patients with an AHI up to 65. The AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) policy statement supports the upper airway stimulator as a second line treatment after CPAP has been failed.

Outpatient surgery, 64582 x 1, hypoglossal nerve stimulator is the best available treatment for this patient at this time. The patient has trialed and failed the gold standard treatment of CPAP. The requested is medically necessary for this patient at this time.

"Conclusions: More than 9 out of 10 of the respondents were interested in trying emerging technologies to treat OSA, most preferring CTES (continuous transcutaneous electrical stimulation). Less sleepy patients were more likely to choose less invasive treatments. These findings will likely impact on future research and development of therapies for sleep-disordered breathing." (Campbell, et al, 2015)

"Conclusions: This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. Further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes." (Certal, et al, 2015)

The carrier's denial of Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator should be overturned.