Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for partial glossectomy using radiofrequency. Findings:  The physician reviewer found that the patient with known history of obstructive sleep apnea (OSA) and underlying behavioral health condition with bipolar disorder. The patient has endorsed symptoms of ongoing sleep disordered breathing, snoring and obstructive sleep apnea syndrome. The patient does have a known history of undergoing surgical intervention for symptoms of OSA which included both an uvulopalatopharyngoplasty in addition to genioglossus advancement surgery performed in 2006.  Per the records, it was noted that the surgical intervention improved symptoms of oxygenation during sleep patterns as the postoperative study showed reduction of apnea hypopnea index down to 18 episodes per hour sleep from a baseline which had been documented at 25.2 episodes per hour sleep.  Continuous positive airway pressure (CPAP) therapy has been trialed. However, the patient reports that the use of the device has become intolerable and did not achieve any significant improvement. The patient has also utilized mouth appliance, again apparently without significant improvement. Review of the patient's physical examination documented in the current medical records demonstrates that the patient remains overweight with her weight documentation of 90.3 kg, and body mass index equal to 35 kg per meter squared. There is a suggestion that the base of tongue is large with no documentation of any measurements despite the use of flexible fiberoptic laryngoscopy. Polysomnogram with CPAP titration study was performed  and documented normal sleep efficiency of 80.2%, moderate sleep apnea with apnea/hypopnea index of 25.2 episodes per hour sleep and oxygen saturation nadir down to 64% from a baseline of 92%. The provider recommended partial glossectomy using radiofrequency. Per the Health Plan the requested services are investigational for the treatment of the patient. There is a lack of medical evidence showing effectiveness of single radiofrequency ablation of the tongue base in patients with symptoms of obstructive sleep apnea especially those who have undergone prior multilevel surgical interventions for these symptoms. There is no active clinical evidence that demonstrates dramatic improvement of this patients symptomatology. This patient already has achieved some degree of benefit with prior multilevel surgery achieving reduction of the apnea hypopnea index from severe level to a moderate level. Most of the clinical studies demonstrate some degree of improvement of obstructive sleep apnea but these studies usually combine therapeutic interventions such as the combination of uvulopalatopharyngoplasty in addition to radiofrequency of the tongue base.  Therefore, in this patients case, partial glossectomy using radiofrequency is not likely to be superior to other modes of therapy in the treatment of this patient. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.