Cpap denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 63-year-old man who was originally diagnosed with obstructive sleep apnea (OSA) in 1998. At that time he had symptoms of excessive daytime fatigue, periodic leg movement and hypertension. He had a sleep study with an apnea index of 23 events per hour and oxygen desaturations to 85%. CPAP was prescribed at a pressure of 9 cm of H2O and was clinically effective. As an added benefit, the patient’s hypertension resolved with the use of CPAP. The patient had a recurrence of his daytime fatigue and repeat polysomnography was performed in 2003. The apnea index was 7.2 without CPAP and 9.9 with CPAP and he had oxygen desaturations of 85.8 without CPAP and 88.7 with CPAP. The study also documented periodic leg movements. As a result of this study, his CPAP pressure was increased to 11 cm of H2O. The patient’s CPAP device apparently wore out, and a replacement unit was provided.

The patient is a 37-year-old male with a history of waking from sleep with a rapid pulse rate and difficulty breathing. He also has a history of hypersomnolence, vivid nightmares, and headaches. Chart notes also relate a history of snoring and witnessed apneas. Possible diagnoses for this patient have included asthma, gastroesophageal reflux disease (GERD), and obstructive sleep apnea (OSA). Evaluation by an otolaryngologist resulted in a diagnosis favoring GERD and the patient was started on Prevacid. A gastroenterologist evaluated the patient and did not agree with a diagnosis of GERD, but recommended an upper GI series for further evaluation. The gastroenterologist also noted the possibility of SVT associated with the patient’s known mitral valve prolapse. The patient had a polysomnography showing no significant evidence of sleep apnea with a RDI of 2.3 and oxygen saturation at 93%.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Continuous Positive Airway Pressure (CPAP). She has witnessed apnea, morning headaches and daytime somnolence. She was referred to the sleep clinic for evaluation for obstructive sleep apnea (OSA). The sleep study report revealed mild OSA, with an apnea–hypopnea index (AHI) of 5.9. Respiratory events consisted of episodic clusters of obstructive apneas and hypopneas. Nadir oxygenation was 87.0 percent. Time spent with an oxygenation level of less than 90 percent was 0.9 minutes. Continuous positive airway pressure (CPAP) therapy was recommended at a follow-up visit. The therapy data summary noted the enrollee had an insufficient trial on auto CPAP therapy due to less than four hours of use. A repeat CPAP trial was recommended.

The patient is a 39-year-old male who underwent evaluation with polysomnography for suspected obstructive sleep apnea. In a letter from the patient’s physician it is noted that the patient has a history of hypersomnia, as well as excessive daytime sleepiness. The information submitted does not indicate any other associated symptoms or findings such as witnessed apneas, mood disorder, cardiovascular disease or hypertension. Polysomnography performed on 8/8/04 shows an AHI of 2.8 with an oxygen saturation nadir of 92% during a total sleep time of approximately 86 minutes. The subsequent CPAP titration study shows an AHI of 1.3 with “oxygen saturation stable above 90%” – total study time was 314 minutes. Sleep efficiency for the initial study was calculated at 25.4% with sleep efficiency for the titration study calculated at 86.5%.

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