Sleep Apnea denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. A review noted that “Glucagon-like peptide-1 (GLP-1) receptor agonists are a class of antidiabetic medications that have shown promise in encouraging glycemic control and promoting weight loss in patients with or without type 2 diabetes”. The authors summarized and discussed the weight loss results from clinical trial programs. The authors noted that all three clinical trials demonstrated that semaglutide has superior efficacy compared with placebo and other antidiabetic medications in weight reduction, which led to the U.S. Food and Drug Administration (FDA) approval of semaglutide (Wegovy) for weight loss. Semaglutide was FDA-approved for diabetes type 2 treatment under the name Ozempic in 2017 and for weight management under the name Wegovy in 2021.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a sleep study. In this case, the records indicate the presence of daytime fatigue, accompanied by snoring and hypersomnia, which was significant enough to contribute to a motor vehicle accident. Despite the absence of an elevated body mass index (BMI) or nocturnal hypoxemia, the records highlight the coexistence of insomnia and attention deficit hyperactivity disorder (ADHD), which are both potentially linked to undiagnosed sleep apnea. Researcherswith ADHD, such as difficulties concentrating, ineffective planning, and restlessness. The authors further note that the treatment of OSA is associated with an improvement in ADHD symptoms. As with ADHD, insomnia and OSA may also share overlapping symptoms.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for supplemental oxygen and prospective authorization and coverage for an in-home sleep study. Findings: The physician reviewer found that supplemental oxygen is used in the treatment of various clinical disorders, both respiratory and non-respiratory; relief hypoxia, treatment of pulmonary hypertension, polycythemia secondary to hypoxemia, chronic disease states complicated by anemia, cancer, migraine headaches, coronary artery disease, seizure disorders, sickle-cell crisis, and sleep apnea. In this case, the documentation submitted for review does not support the need for supplemental oxygen. The cardiac and respiratory examinations were unremarkable.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. The Health Plan has denied this request indicating the enrollee was not experiencing an emergency medical condition on the date of service at issue.Findings: At issue in this case is whether the enrollee received emergency medical services on the date(s) of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability o…

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 sleep apnea, then check the rights and deadlines that apply to your plan.