Diagnosis: Severe Obstructive Sleep Apnea
Treatment: Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator
The insurer denied coverage for Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator.
The denial is overturned.

The patient presents with severe obstructive sleep apnea (OSA) with an apnea hypopnea index (AHI) of 66 despite a uvulopalatopharyngoplasty and nasal surgery. The patient has tried and failed treatment with continuous positive airway pressure (CPAP) after trying multiple masks. The patient's body mass index (BMI) is 31.6. The patient has undergone a drug induced sleep endoscopy (DISE) that showed no concentric pattern of upper airway collapse (CCC). The patient's treating provider is asking for approval of a hypoglossal nerve stimulator (HNS) to treat his OSA.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. HNS is a non-anatomical modifying surgery to treat OSA.

According to a review by Baptista, et al (2020), "Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome" and "In the context of a customized management for OSA patients, the HNS represents one of the most promising tools."

Outpatient surgery, 64582 x 1, HNS needs to have final approval from the appropriate regulatory bodies for this diagnosis.

Thus, HNS has final approval from the appropriate regulatory bodies for the patient's diagnosis of OSA.

This patient is a good candidate for outpatient surgery, 64582 x 1, HNS.

The outpatient surgery, 64582 x 1, HNS is the best available treatment for this patient at this time.

A multicenter prospective observational study by Thaler E, et al (2019) examined the outcomes of patients receiving upper airway stimulation therapy (another term for HNS) for patients who had failed CPAP. The study enrolled 1,017 patients and found that both AHI and ESS (Epworth sleepiness scale) were reduced at 12-month follow-up. The study concluded that HNS "therapy continues to show significant improvement in subjective and objective OSA outcomes."

Thus, HNS does not have adverse risks over standard treatment/services left available to this patient given he has failed CPAP treatment.

This patient has already tried and failed multiple standard treatment and/or procedures for severe OSA. The next best treatment available is supported by numerous medical studies and standard of care (SOC). Although weight loss has less risk, a letter by the treating provider states, that the patient has already lost weight and his "BMI is not a factor." In conclusion, the requested service, HNS surgery is the next best treatment option for this patient. As illustrated above, it is effective and safe for this patient as supported by numerous studies involving similar patients.

The carrier's denial of Professional Services; outpatient surgery (64582 x 1); HNS should be overturned.