Obstructive Sleep Apnea denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 12-year-old female with a history of sleep apnea. She has a prior history of tonsillectomy and adenoidectomy. She presented to her otolaryngologist with symptoms consistent with obstructive sleep apnea. A sleep study in September 2003 revealed a respiratory disturbance index (RDI) of 5.7 and lowest oxygen desaturation of 93%. This was interpreted at a sleep disorder clinic as mild obstructive sleep apnea. The patient was fitted with a BiPAP and had marked improvement in her symptomatology as documented by her otolaryngologist in May 2004. The patient had been compliant with BiPAP use. The patient then underwent spinal fusion surgery for severe scoliosis. The patient’s otolaryngologist has documented that the patient has become intolerant of CPAP/BiPAP. He has requested authorization for uvulopalatopharyngoplasty and partial glossectomy with radiofrequency.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Inspire device implantation (hypoglossal nerve stimulator). Continuous positive airway pressure (CPAP) has traditionally been the gold standard first-line therapy in the treatment of obstructive sleep apnea (OSA). However, failure to comply with CPAP is common because it requires a nasal or full-face mask during sleep, which many patients find intolerable. As a result, tonsillectomy with or without uvulopalatopharyngoplasty (UPPP) has been utilized as an alternative surgical option. While the procedure can be effective in properly selected patients, it can fail to reduce the AHI in a meaningful manner, and the patients who do see an improvement frequently relapse. Notably, this was the case with this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for partial glossectomy using radiofrequency. Findings: The physician reviewer found that the patient with known history of obstructive sleep apnea (OSA) and underlying behavioral health condition with bipolar disorder. The patient has endorsed symptoms of ongoing sleep disordered breathing, snoring and obstructive sleep apnea syndrome. The patient does have a known history of undergoing surgical intervention for symptoms of OSA which included both an uvulopalatopharyngoplasty in addition to genioglossus advancement surgery performed in 2006.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. Per the records, he has been treated with Xanax, Ambien, trazodone and temazepam. The provider noted the patient had been seen by a psychiatrist in the past, but he did not want to take the medication that was recommended. The patient requested a refill of Xanax for daily use due to anxiety. The provider noted that daily use of Xanax was not an appropriate treatment for the management of anxiety. The provider prescribed Xanax 0.5 mg with a quantity of 10 to use as needed. The patient requested Xanax for chronic insomnia. He has requested authorization and coverage for Xanax 0.5 mg tablets, 30 tablets per 30 days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving obstructive sleep apnea, then check the rights and deadlines that apply to your plan.