Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe sleep apnea based

Treatment: a facility-based sleep study (code 95810)

The insurer denied coverage for a facility-based sleep study (code 95810)

The denial is overturned

This case involves a male diagnosed with severe sleep apnea based on sleep testing, which had been administered approximately 10 years prior with an additional study 2 years before his office visit. He claimed to have tried using a continuous positive airway pressure (CPAP) device 5 times and his wife endorsed loud snoring and reported that the patient stopped breathing in his sleep. The patient tended to sleep in a supine position, typically awaken with a dry mouth, and endorsed profound daytime drowsiness. His Epworth sleepiness scale score at the time of the visit was 19. The patient appeared to be claustrophobic, indicating the minimal use of the CPAP device. The patient reported falling asleep quickly around 9 at night and waking several times in the middle of the night. The patient also reported neuropathy and restless leg syndrome, with a history of profound iron deficiency with receipt of iron infusions. The report noted a weight gain of approximate 20 pounds in the past 2 years with claims that a lot of this was water weight, given that when diuresed, he recently lost 30 pounds. His examination noted an elevated body mass index of 46.1, nasal congestion, low-lying soft palate, Mallampati score of 3, crowded oral cavity, absent tonsils, enlarged tongue, and mild occluded bite with many missing mandibular molars.  He also had 4+ pitting edema to the bilateral lower extremities. The physician stated the patient had not tried a bilevel positive airway pressure (BiPAP) device, which could be a good next step. The physician was concerned about the patient's degree of sleepiness and his comorbidities. Records noted the patient was sent for an in-lab sleep study with claims that the patient could not tolerate CPAP/BiPAP and was not a candidate for hypoglossal nerve stimulation. The physician was considering tracheostomy, but previous sleep study suggested mild apnea. The physician stated the patient needed in lab sleep testing for accurate assessment of severity before surgery.  

Literature states that polysomnography (PSG) is considered to be the gold standard for diagnosing sleep-related breathing disorders, which include obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation/hypoxia. PSG can also be utilized to evaluate for other sleep disorders, including nocturnal seizures, narcolepsy, periodic limb movement disorder, and rapid eye movement sleep behavior disorder. In the case of this patient, the physician was requesting an in-lab sleep study as the physician was considering a tracheostomy to be the neck step in the treatment process given the patient's history of severe sleep apnea, snoring, observed apneic episodes, and inability to use a CPAP/BiPAP. The intention was to assess the patient's severity of apnea prior to surgery.  Because of the inconsistent reports pertaining to the extent of the patient's apnea with the physician claiming that prior sleep studies suggested both mild apnea and severe sleep apnea and a current study would help confirm the extent of the patient's condition.  This, in turn, will help to direct treatment planning and would be medically necessary if the patient is being considered for tracheostomy. Therefore, the medical necessity of the request was established.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a facility-based sleep study (code 95810) is overturned. Medical Necessity is substantiated.