Sleep Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oral appliance (E0486) provided. Findings: The physician reviewer found that given the body of evidence to support the use of oral appliance therapy, the device at issue was effective in the treatment of this patient’s OSA. While the guidelines recommend CPAP as the first line therapy for patients diagnosed with OSA, they acknowledge that not all patients are tolerant of CPAP. In that setting, it is generally a standard practice to use alternative therapies to CPAP for patients with OSA who do not tolerate or respond to CPAP.

The patient is a 29-year-old female with a history of primary hypersomnia. A sleep study revealed sleep latency of 9.25. The results indicated an alerting medication is required to prevent excessive sleepiness at work and to reduce safety risks. The patient has been taking Provigil since 1999 with excellent response documented. The patient’s provider, a psychiatrist and sleep study specialist, recommends the patient be continued on Provigil. The Health Plan has denied authorization for Provigil on the basis it is not medically necessary for treatment of the patient’s hypersomnia.Review of the submitted records demonstrates Provigil has been efficacious for treatment of the patient’s hypersomnia. The introduction of alternative treatments may provide more chance for abuse and possible detrimental side effects.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for actigraphy testing performed for evaluation of the enrollee, who reported a history of excessive daytime sleepiness. Findings: The 3 physician reviewers found that Circadian rhythm sleep disorders, such as delayed sleep phase syndrome, have traditionally been diagnosed on the basis of patient histories. Traditionally, sleep logs or sleep diaries have been utilized in clinical practice to record a patient’s sleep wake schedule. In the past decade, actigraphy was developed as a technology, and it gained use in research studies and in some aspects of clinical practice. Colleagues published a study in which actigraphy and sleep logs were both utilized to evaluate patients with insomnia.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea. Findings: Three physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity; long-term adherence rates approach 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology.

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