Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea. 
Treatment: outpatient procedure (64582 X 1). 
The insurer denied coverage for outpatient procedure (64582 X 1). 
The denial is overturned. 

According to the medical records, the patient presented with obstructive sleep apnea (OSA). The patient has symptoms of snoring and restless sleep with apneas. Most recent nocturnal, laboratory-based polysomnography (PSG) demonstrated an apnea-hypopnea index (AHI) of 57.2. CPAP (continuous positive airway pressure) was not well tolerated. Drug-induced sleep endoscopy (DISE) showed anteroposterior collapse. The request is for (64582 - Open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array X 1), which is under review. 

The outpatient procedure (64582 - Open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array X 1) is considered medically necessary in this patient. According to the medical records, the patient demonstrates: 

	Age greater than 22 
	Body Mass Index (BMI) is less than 32 ( The patient's BMI is 27.98) 
	Nocturnal, laboratory-based polysomnography (PSG) within 24 months 
	Primarily obstructive events are less than 25% (The patient's obstructive events are 22%) 
	Apnea-hypopnea index (AHI) between 20 and 65 (The patient's apnea-hypopnea index is 57.2) 
	Unable to tolerate continuous positive airway pressure (CPAP) (The CPAP was not well tolerated with this patient) 
	Absence of complete concentric collapse 

The medical literature supports usage of this technique: 

According to Mashaqi et al., (2021), "Obstructive sleep apnea (OSA) is a common sleep disorder that affects all age groups and is associated with many co-morbid diseases (especially cardiovascular diseases). Continuous positive airway pressure (CPAP) is the gold standard for treating OSA. However, adherence to CPAP therapy has been a major challenge with an estimated adherence between 20% and 80%. Mandibular advancement devices (MAD) are a good alternative option if used in the appropriate patient. MAD are most effective in mild and moderate OSA but not severe OSA. Surgical options are invasive, not appropriate for severe OSA, and associated with pain and long healing time. Hypoglossal nerve stimulation (HGNS), or upper airway stimulation (UAS), is a novel therapy in treating moderate and severe degrees of OSA in patients who cannot tolerate CPAP therapy. We concluded that hypoglossal nerve stimulation is a very effective and novel alternative therapy for moderate and severe OSA in patients who cannot tolerate CPAP therapy. Adherence to HGNS is superior to CPAP. However, more developments are needed to ensure the highest safety profile." 

Given the above, the outpatient procedure (64582 - Open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array X 1) is considered medically necessary in this patient. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for outpatient procedure (64582 X 1) is substantiated.