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202010-131706

2020

Empire Healthchoice Assurance Inc.

Indemnity

Ears/ Nose/ Throat

Surgical Services

Medical necessity

Upheld

Case Summary

Ear/Nose/Throat
Surgical Services (All)

Diagnosis: sleep complaints
Treatment: Uvulopalatopharyngoplasty (UPPP)
The insurer denied Uvulopalatopharyngoplasty (UPPP).
The health plan's determination is upheld.

This is a female with a history of "sleep complaints". These include snoring, daytime somnolence, fatigue, and frequent napping. Nocturnal gassing and apneas have been witnessed. A home sleep study revealed an apnea hypopnea index (AHI) of 7. Exam revealed enlarged tonsils, and a redundant soft palate and uvula. Endoscopy demonstrated retropalatal narrowing and mild lingual enlargement. The patient declined a trial of continuous positive airway pressure (CPAP) as she stated that she has a history of claustrophobia with face coverings. She elected uvulopalatopharyngoplasty (UPPP) with tonsillectomy, which is under review.

The requested uvulopalatopharyngoplasty is not medically necessary for this patient. According to Adil (2017), if a patient is unable to tolerate CPAP therapy, then surgery can be considered. General indications for surgical intervention include mild obstructive sleep apnea with excessive daytime fatigue, an apnea-hypopnea index of 15 or more, oxyhemoglobin desaturation less than 90%, and/or cardiac arrhythmias associated with obstructions. These criteria are not met. In a review of the literature by Stuck 92018), the authors concluded that uvulopalatopharyngoplasty with tonsillectomy reduces respiratory events and daytime sleepiness in adult patients with obstructive sleep apnea and was superior to non-treated controls in this regard. The authors called for further research to establish the long-term benefit, the impact on cardiovascular morbidity and the role of these procedures in variety of available treatment options for obstructive sleep apnea. Based upon the clinicals provided, uvulopalatopharyngoplasty is not clinically appropriate and is not medically necessary for this patient.

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