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202207-151140

2022

Fidelis Care New York

Medicaid

Respiratory System

Diagnostic Testing (other than Radiology)

Medical necessity

Upheld

Case Summary

Diagnosis: Sleep Apnea.
Treatment: Sleep Study (polysomnography/titration) in a sleep center.

The insurer denied Sleep Study (polysomnography/titration) in a sleep center. The health plan's determination is upheld.

This is the case of a male patient who was referred to the sleep lab to have a sleep study. The patient has been complaining of symptoms of sleep apnea including sleepiness, snoring, witnessed apnea, hypertension and obesity with body mass index (BMI) of 30. The patient had a home sleep study that showed severe sleep apnea with an apnea hypopnea index (AHI) of 42 associated with significant hypoxemia. The provider is requesting the coverage of a Sleep Study (polysomnography/titration) in a sleep center to treat this patient's symptoms of sleep apnea.

Sleep Study (polysomnography/titration) in a sleep center is not medically necessary for this patient. This patient suffers from severe sleep apnea associated with significant hypoxemia. There is no evidence that the patient failed or has contra-indication to home auto Continuous Positive Airway Pressure (CPAP) or auto BIPAP (Bi-level positive airway pressure). The patient does not have any medical (i.e. chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), neuromuscular disorder, or sleep (i.e. narcolepsy, central apnea) comorbidities that can degrade the accuracy of an auto- CPAP or auto BIPAP. There is no evidence that the patient failed auto CPAP or auto BIPAP. The latter is as adequate as an in lab sleep study titration study for treatment of sleep apnea. Therefore, the Sleep Study (polysomnography/titration) in a sleep center is not medically necessary. A standard home auto CPAP / auto BIPAP can be performed instead followed by nocturnal oximetry while on auto CPAP or auto BIPAP.

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