Diagnosis: Obstructive sleep apnea

Treatment: Obstructive sleep apnea appliance

The insurer denied coverage for obstructive sleep apnea appliance. The denial was upheld.

This patient is a male currently diagnosed with chronic fatigue, deviated nasal septum and obstructive sleep apnea. The patient underwent a sleep study revealing an apnea-hypopnea index (AHI) was 4. The patient's respiratory disturbance index (RDI) was 10. The patient underwent a nasal vestibular stenosis repair, a septoplasty turbinectomy, and sleep endoscopy. The sleep endoscopy that was performed revealed a severe to complete base of tongue (BOT) collapse, which was significantly improved with the jaw thrust. The patient had poor concentration and memory, chronic fatigue and severe daytime somnolence. The provider stated the patient was an excellent candidate for a mandibular advancement device.

The American College of Physicians recommends, "mandibular advancement device (MAD) as an alternative therapy for patients who prefer it or who do not tolerate or comply with CPAP treatment." The American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guideline recommends, "sleep physicians prescribe oral appliances for treatment of adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy."

The Centers for Medicare and Medicaid Services state that the apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) must be greater than or equal to 15 events per hour with a minimum of 30 events; or, the AHI or RDI must be greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke; or the AHI greater than 30 or the RDI greater than 30 and meets either of the following: the beneficiary is not able to tolerate a positive airway pressure (PAP) device; or the treating physician determines that the use of a PAP device is contraindicated.
The patient had poor concentration and memory, chronic fatigue and severe daytime somnolence. The patient had an AHI of 4 and an RDI of 10. Although the patient could not utilize CPAP, the literature did not support treatment for patients with an AHI less than 5 or RDI of 10. Therefore, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient. The obstructive sleep apnea appliance is not considered medically necessary for this patient.

Based on the above, the medical necessity for obstructive sleep apnea appliance is not substantiated. The insurer's denial is upheld.