Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male who has a history of snoring and obstructive sleep apnea (OSA). An initial baseline polysomnogram, performed in December 2013, confirmed moderate to severe OSA with an apnea hypopnea index (AHI) of 56.5 episodes per hour sleep. Oxygen saturation nadir was 87 percent. A follow-up titration study was performed confirming that bilevel positive airway pressure (BPAP) of 18 and expiratory positive airway pressure (EPAP) of 13 showed improvement of the patients symptoms, but the patient has become intolerant to the continuous positive airway pressure (CPAP) therapy. The submitted medical records document that the patient underwent procedures to improve symptoms of sleep disordered breathing including nasal surgery, septoplasty and inferior turbinate reduction. The surgical interventions improved and eliminated the majority of the patient's symptoms of snoring but did not improve all the sleep parameters. Drug-induced sleep endoscopy was performed on 7/1/15 under anesthesia.  The report confirmed evidence that the patient does have a severe caudal collapse in addition to severe lateral collapse of the retropharyngeal palate. On 8/5/15, the patient underwent further surgical intervention which included suspension expansion pharyngoplasty. This was performed to improve the patients symptoms of airway obstruction.  Postoperative subjective evaluation confirmed that the patient had some degree of improved sleep quality without velopharyngeal insufficiency or dysphagia. There is a report of a home sleep study performed following these interventions on 11/24/15 confirming that the AHI was at 34.5 episodes per hour of sleep and that the oxygen saturation nadir was 85%. The provider suggested upper airway stimulation to improve the patient's symptoms of OSA. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request as investigational for treatment of this patients medical condition. In this patients case, the requested services are not likely to be more effective than other forms of therapy for treatment of his OSA. The medical studies support implantation of cranial nerve stimulator in select patients. To be considered for surgical implantation of a cranial nerve stimulator, patients must have previously failed prior surgical management including uvulopalatopharyngoplasty, nasal reconstruction and other techniques in addition to therapy and failure with CPAP and mandibular advancement prostheses. Patients who are candidates for upper airway stimulation therapy must have undergone appropriate evaluations with polysomnogram, having reduced body mass index (BMI) of less than 32, along with objective upper airway evaluation measures documenting narrowing of the retro-palatal airway (Doghramji and Boon). The patient in this case, does not meet those criteria. The patients BMI is greater than 32. Moreover, there was no indication demonstrating that the patient has sustained any weight loss with prior medical management to reduce the BMI score below 32. Additionally, the drug-induced sleep endoscopy confirmed evidence of a very severe collapse which may be concentric. As such, implantation of cranial nerve stimulator is not likely to be more effective than other standard modalities available for treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.