Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that FDA-approved hypoglossal nerve neurostimulation is considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when all of the following criteria are met: 1. Beneficiary is 22 years of age or older; and 2. Body mass index (BMI) is less than 35 kg/m2; and 3. A polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant; and 4. Beneficiary has predominantly obstructive events (defined as central and mixed apneas less than 25% of the total AHI); and 5. AHI is 15 to 65 events per hour; and 6. Beneficiary has documentation that demonstrates CPAP failure (defined as AHI greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week or the CPAP has been returned) including shared decision making that the patient was intolerant of CPAP despite consultation with a sleep expert: and 7. Absence of complete concentric collapse at the soft palate level as seen on a drug-induced sleep endoscopy (DISE) procedure; and 8. No other anatomical findings that would compromise pe
rformance of device (e.g., tonsil size 3 or 4 per standardized tonsillar hypertrophy grading scale). You can find this rule in the Local Coverage Determination (LCD) - Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38528) - Effective June 14, 2020. The rules say that hypoglossal nerve neurostimulation is considered not medically reasonable and necessary for all other indications (than the ones listed above). Non-FDA-approved hypoglossal nerve neurostimulation is considered not medically reasonable and necessary for the treatment of adult obstructive sleep apnea due to insufficient evidence of being safe and effective. You can find this rule in the Local Coverage Determination (LCD) - Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38528) - Effective June 14, 2020. The rules say that hypoglossal nerve neurostimulation is considered not medically reasonable and necessary when any of the following contraindications are present: 1. Beneficiaries with central and mixed apneas that make up more than one-quarter of the total AHI.
2. Beneficiaries with an implantable device could experience unintended interaction with the HGNS implant system. 3. BMI equal to or greater than 35 4. Neuromuscular disease 5. Hypoglossal-nerve palsy 6. Severe restrictive or obstructive pulmonary disease 7. Moderate-to-severe pulmonary arterial hypertension 8. Severe valvular heart disease 9. New York Heart Association class III or IV heart failure 10. Recent myocardial infarction or severe cardiac arrhythmias (within the past 6 months) 11. Persistent uncontrolled hypertension despite medication use 12. An active, serious mental illness that reduces the ability to carry out Activities of Daily Living (ADLs) and would interfere with the patient's ability to operate the HNS and report problems to the attending provider. 13. Coexisting nonrespiratory sleep disorders that would confound functional sleep assessment 14. Beneficiaries who are, or who plan to become pregnant. 15. Beneficiaries who require Magnetic Resonance Imaging (MRI) with model 3024. 16. Beneficiaries, who require MRI with model 3028, can undergo MRI on the head and extremities if certain conditions and precautions are met. Please refer to the Manufacturer Guidelines for this model and future models for more information. 17. Beneficiaries who are unable or do not have the necessary assistance to operate the sleep remote. 18. Beneficiaries with any condition or procedure that has compromised neurological control of the upper airway. You can find this rule in the Local Coverage Determination (LCD) - Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38528) - Effective June 14, 2020.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.