Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Sleep Apnea.
Treatment:  Diagnostic testing (sleep study - 95811 x1).

The insurer denied Diagnostic testing (sleep study - 95811 x1).  The denial is upheld.

The patient is an adult male who was suspected of having obstructive sleep apnea (OSA). He had complaints of daytime sleepiness (Epworth Sleepiness Scale [ESS] 13/24) and non-restorative sleep. The patient had a body mass index (BMI) of 28.5 and a 17-inch neck. The patient underwent a home sleep test. The test returned positive for obstructive sleep apnea with an apnea hypopnea index (AHI) of 6.5 and an oxygen nadir of 81 percent. Following the home sleep test, the patient was referred for an attended continuous positive airway pressure (CPAP) titration study in the sleep center. A request was made of his health plan (Fidelis Care) for prior approval of an attended titration study. That request was denied based on utilization management guidelines (MCG). This denial has since been appealed to New York State (NYS).

The proposed treatment is not medically necessary.

In this case, the patient has been diagnosed with obstructive sleep apnea (OSA). There has been a gradual shift away from the performance of sleep testing and treatment in the attended setting to the home/ambulatory setting/environment. Studies have otherwise shown that the provision of therapy services (via auto-titrating positive airway pressure [PAP]) can deliver equivalent results to patients in place of them undergoing titration studies in a sleep center (see Rosen et al., Berry et al.). As was noted in recent practice guidelines from the American Academy of Sleep Medicine (AASM): "The TF [Task Force] identified 10 RCTs that compared initiation of PAP using home APAP versus an in-laboratory PAP titration. Meta-analyses demonstrated no clinically significant differences in adherence, sleepiness, or QOL between APAP at home and in-laboratory PAP titration. The overall quality of evidence for this recommendation was high." 
(Patil et al.). The authors also noted that their conclusion applied to all patients who had been diagnosed with obstructive sleep apnea, including those diagnosed with a "severe" apnea hypopnea index on initial testing. In their accompanying publication, Patil and colleagues also stated that: "The potential benefits of PAP initiation using home APAP over in-laboratory titration are a reduced time to initiation of therapy, particularly in areas with limited laboratory resources... and greater access to care." (2019a).

Likewise, other publications have presented analyses showing that the provision of care with the use of an auto-positive airway pressure (PAP) (as opposed to having a patient undergo an attended titration) otherwise is a more efficient manner in which care can be provided. (Hui et al., Bravata et al.)

In this case, the service under review is not the most efficient manner in which care can been provided. The patient is noted to otherwise be compliant with positive airway pressure (PAP) therapy at this time. There is not a clinical reason why re-titration (if indicated) cannot be achieved with auto-positive airway pressure (PAP). An attended titration study at this time would otherwise exceed the patient's clinical needs. Consequently, it cannot be said that the requested service is medically necessary.