Cpap Machine denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement, and authorization and coverage for a CPAP machine. The enrollee has a history of obesity, with a body mass index of 34.45 and obstructive sleep apnea (OSA). At a follow up visit with his pulmonologist for hypersomnia, the enrollee indicates he feels better when he uses the CPAP machine all night, but he has problems with his CPAP mask. Physical exam showed a small blister on the left side of the bridge of the enrollee’s nose, so a referral for mask fitting by respiratory therapist was made. The enrollee indicates his compliance with more regular CPAP use has been affected because of the facial blister caused by the CPAP mask.

Nature of Statutory Criteria/Case Summary: The enrollee is requesting reimbursement for CPAP machine. According to the record, the patient has a history of recurrent laryngeal papilloma. He underwent a flexible scope laryngoscopy and the physician noted the enrollee had worn a continuous positive airway pressure (CPAP) mask for sleep apnea for many years with resolution of daytime somnolence; however, the mask began improperly fitting and leaking. Results of the original study are not provided. His body mass index is 28.6 and his neck circumference 17.5 inches. A home sleep test was performed indicating mild sleep disordered breathing and obstructive sleep apnea (OSA). He had three minutes of total study time below 88% oxygenation. His physician prescribed CPAP supplies for the diagnosis of OSA to replace the old one that stopped working after approximately 10 years.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine. Treatment with a CPAP is considered appropriate when an AHI greater than or equal to 15 is determined by a home or laboratory based sleep study and when the patient has either had an APAP (automatic positive airway pressure) titration trial or a split-night sleep study to determine the appropriate settings of the CPAP. Ongoing use of a CPAP device is indicated for patients who demonstrate compliance with therapy. In a 90-day period, the patient should use the CPAP device for greater than or equal to four hours per night on 70% of nights. Type 4 devices have highly variable diagnostic performance and most do not include a conventional measure of sleep. This can result in limited information.

The patient is a 30-year-old male with complaints of daytime hypersomnolence and fatigue. He reports snoring, waking up gasping for air, and difficulty going to sleep and staying asleep. The patient has an Epworth Sleepiness scare score of 10. An overnight polysomnography study obtained in December 2004 documents mild upper airway resistance, but no significant obstructive sleep apnea. Overall sleep efficiency was 85.3%. Apnea/hypopnea index (AHI) was 4.9. Oxygen saturation dropped from a baseline of 97% to a low of 93%. At the time of this study, the patient was 5’7” weighing 160 pounds. Therapeutic treatment options based upon the results of the polysomnogram included weight loss (if applicable), use of oral appliances, application of surgical techniques (if clinically indicated), and a second overnight sleep study for the purpose of CPAP titration.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Cpap Machinewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.