Diagnosis: Obstructive sleep apnea syndrome
Treatment: Upper airway stimulation treatment for obstructive sleep apnea (outpatient surgery code 64568 x 1, 0466T x1)
The insurer denied coverage for the upper airway stimulation treatment for obstructive sleep apnea (outpatient surgery code 64568 x 1, 0466T x1).
The denial is overturned.

This is a female patient who has been recommended to undergo the implantation of an upper airway stimulation device. The patient has been diagnosed with obstructive sleep apnea (OSA) syndrome. The patient has had a trial and failure of continuous positive airway pressure (CPAP). The patient has a body mass index (BMI) of 29.2. The patient underwent a sleep study revealing an apnea-hypopnea index (AHI) of 24.4 in the supine position, and her respiratory distress index (RDI) was 15.1. The patient's sleep study revealed evidence of moderate OSA with moderate oxygen desaturation. The patient's breathing events did increase in the supine position and titration may be considered. The patient underwent a drug-induced sleep endoscopy which did not reveal complete concentric collapse. It has been recommended that the patient utilize an upper airway stimulation unit.

As per literature review, CPAP is a first-line of treatment for OSA; however, long-term use for many patients is suboptimal. The hypoglossal nerve stimulator in the United States (U.S.) was approved by the Food and Drug Administration (FDA) for the treatment of moderate and severe OSA. A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes. In their updated (2017) position statement, the American Academy of Otolaryngology-Head and Neck Surgery stated that it considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Candidates for this therapy are selected based on appropriate polysomnographic testing, age, BMI and objective upper airway evaluation. Literature notes that patients with OSA, unable to tolerate CPAP, and with an elevated BMI can be successfully treated with upper airway stimulation therapy.

In this case, this patient meets all inclusion criteria to be a candidate for this requested procedure and device.

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

Based on the above, the medical necessity for the upper airway stimulation treatment for OSA (outpatient surgery code 64568 x 1, 0466T x1) is substantiated. The insurer's denial should be overturned.