202110-142811
2021
Empire Healthchoice Assurance Inc.
Indemnity
Ears/ Nose/ Throat
Durable Medical Equipment (DME) (including Wearable Defibrilllators)
Medical necessity
Overturned
Case Summary
Diagnosis: Sleep Apnea.
Treatment: Oral Device (code E0486).
The insurer denied the Oral Device (code E0486).
The denial is overturned.
The patient is a male with mild obstructive sleep apnea. The health plan's denial of an oral device was based upon AHI (apnea-hypopnea index) of 7 and no other symptoms. This is being appealed.
Yes, the oral device is medically necessary.
Patient had an AHI (apnea-hypopnea index) of 7.5, and 10.9 while supine. This is consistent with mild obstructive sleep apnea. The patient refuses CPAP (continuous positive airway pressure) therapy, as he is claustrophobic and cannot tolerate any restrictive movement during sleeping. An oral appliance for treating mild to moderate OSA (obstructive sleep apnea) is considered first-line treatment, especially if the patient cannot wear a CPAP (continuous positive airway pressure) device.
No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Please see the rationale, above.