Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The insurer denied coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The denial is overturned. 

This is a male patient who was diagnosed with severe obstructive sleep apnea (OSA) based on a sleep study with an apnea-hypopnea index (AHI) 32 and no evidence of central sleep apnea.  The patient has a normal body mass index (BMI) of 31.7.  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 it and cannot wear it for more than 2 hours at night. The patient's sleep endoscopy showed no concentric collapse.  All of these factors make this patient a good candidate for the upper airway stimulator.

As per Woodson et al. (2016), "Long-term 3-year improvements in objective respiratory and subjective quality-of-life outcome measures are maintained. Adverse events are uncommon. [Upper airway stimulator (UAS)] is a successful and appropriate long-term treatment for individuals with moderate to severe [obstructive sleep apnea (OSA)]." 

In this case, this patient meets the criteria for the upper airway stimulation device to treat his severe OSA. The patient is a good candidate for hypoglossal nerve stimulation or Inspire upper airway stimulation system. Inspire therapy is indicated for patients with the following characteristics: meets the minimum age requirement, has moderate to severe OSA (AHI range from 15-65 with <25% central apneas), unable to use CPAP, free of complete concentric collapse at the palate, and Inspire therapy has not been tested in people with a BMI greater than 32. This patient meets all criteria.

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all patients are candidates for upper airway stimulation 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. In this case, this patient meets the criteria for the upper airway stimulation device to treat his severe OSA. The patient has tried CPAP, and different masks to try and tolerate CPAP without success. The patient does not have concentric collapse.  The patient has a BMI of 31.7, and did not have complete concentric collapse at the palate on his sleep endoscopy. The patient's AHI was 32.

The hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial than any of the standard treatments/procedures for this patient.      

The carrier's denial of hypoglossal nerve stimulation or Inspire upper airway stimulation system should be overturned.