Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep Aapnea
Treatment: In-Lab Sleep Study
The insurer denied the In-Lab Sleep Study.
The denial is upheld.

The patient is a gentleman who underwent a home-based sleep study.  The home-based sleep study documented the presence of severe obstructive sleep apnea with severe oxygen desaturation.  During the home-based sleep study, the patient spent about 12% of the total recorded time with oxygen saturation less than 90%, and 5.9% of the total recorded time with oxygen saturation less than 80%.  The treating physician request for a laboratory-based CPAP (continuous positive airway pressure) titration study.

The In-Lab Sleep Study is not medically necessary.

The patient does not meet the medical necessity criteria for laboratory-based CPAP titration study. In order to meet the medical necessity for a laboratory-based sleep study following documentation is required:

Attended full-channel nocturnal polysomnography is Medically Necessary for evaluating individuals with suspected OSA (obstructive sleep apnea) when:
1)	Results of previous HSAT (home sleep apnea test) are negative, indeterminate or technically inadequate to make a diagnosis of OSA; or
2)	Individual is a child or adolescent (i.e., less than 18 years of age); or
3)	Individual is known to have one or more of the following comorbid medical conditions that prohibits the use of a HSAT:
4)	Significant Chronic Pulmonary Disease as defined by a forced expiratory volume (FEV1) % predicted of <60 (Pellegrino et al., 2005)
5)	Progressive neuromuscular disease/neurodegenerative disorder (examples include, but are not limited to, Parkinson's disease, myotonic dystrophy, amyotrophic lateral sclerosis, multiple sclerosis with associated pulmonary disease, history of stroke with persistent neurological sequelae)
6)	Moderate to severe heart failure (New York Heart Association class III or IV [NYHA, 1994] or left ventricular ejection fraction <= 40 [Yancy et al., 2013; Yancy et al., 2017])
7)	Body mass index (BMI) >50 (DeMaria et al., 2007; Blackstone and Cortes, 2010)
8)	Obesity Hypoventilation Syndrome
9)	Documented ongoing epileptic seizures in the presence of symptoms of sleep disorder. 

The data provided suggested that patient used the Auto-positive airway pressure (pap) for only one night.  The blower time was 6 hours 44 minutes, but the patient use on the machine was 2 hours and 3 minutes.  The machine was set between pressure of 4 cm to 20 cm, but the AutoPap did not change pressure beyond 5 cm.  The AHI (apnea hypopnea index) was 14.2 at 5 cm, suggesting that the machine is not acting properly and sensing properly, with the result that neither adequate trial of AutoPap was completed by the patient.  

In order to meet the medical necessity for CPAP titration in the lab after a home-based sleep study, diagnosis is confirmed for obstructive sleep apnea, and prescription of Auto-positive airway pressure (Pap) has been given, the documentation should document that the patient is compliant and adherent to the CPAP, and that despite adequate use, the patient is still symptomatic, or the auto CPAP has failed to control the events, or complex sleep apnea has been unmasked.  In this case, no such documentation has been provided. Therefore, the patient does not meet the medical necessity criteria for a CPAP titration study in the lab in the absence of documentation of failure of the AutoPap either due to inability to control the patient's symptoms and AHI, or poor patient compliance and tolerance.

In this case, the severity of Oxygen desats is explained by the patient's OSA, and it is not an independent or comorbid sleep condition. The patient used the Auto-positive airway pressure (PAP) for one day. and this is not what a 'trial' is defined as. That was not a trial. Based on the documentation, the patient had no contraindication to AutoPap. Therefore, the patient did not meet the medical necessity for a laboratory-based CPAP titration study, and the documentation provided suggested that the patient has not been placed on an adequate trial of Auto-positive airway pressure (Pap).  Therefore, it cannot be deemed a failure of AutoPap at this time.  The patient is symptomatic, because the patient is not using the AutoPap based on the data provided.  Unless adequate data is provided proving adequate compliance and adherence and the proper function of the AutoPap machine followed by reevaluation by the treating physician, medical necessity cannot be established.