Cpap Machine 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.

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.

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.

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.

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