Hypoglossal Nerve Stimulator denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hypoglossal nerve stimulator. Continuous positive airway pressure (CPAP) therapy has traditionally been the gold standard first-line therapy in the treatment of obstructive sleep apnea (OSA). Failure to comply with CPAP, however, is not uncommon, as many patients find it intolerable. As a result, tonsillectomy with or without uvulopalatopharyngoplasty (UPPP) has historically been utilized as an alternative surgical option. This procedure may be effective in appropriately selected patients. However, it commonly fails to objectively reduce the apnea-hypopnea index (AHI) to any meaningful extent, and those individuals who do improve frequently relapse, as was the case with this patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for insertion of hypoglossal nerve neurostimulator (HNS) electrode and generator and breathing sensor electrode, with implantable neurostimulator electrode, each when component of an HNS (x 2); and implantable neurostimulator pulse generator, dual array; non rechargeable, includes extension when specified as a component of an HNS. Continuous positive airway pressure (CPAP) has traditionally been the gold standard first-line therapy for the treatment of obstructive sleep apnea (OSA). Failure to comply with CPAP, however, is not uncommon as it requires patients to wear either a nasal or full face mask during sleep, which many find uncomfortable.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator (CPT 64568 and CPT 0466T). The U.S. Food and Drug Administration (FDA) has approved hypoglossal nerve stimulation for the treatment of moderate to severe obstructive sleep apnea (OSA) refractory to continuous positive airway pressure (CPAP). However, research comparing its effectiveness to existing alternatives, such as airway surgery or oral appliances, is lacking. Researchers conducted a systematic review comparing oral appliances and CPAP in adult patients with mild to severe OSA. The authors found that although CPAP improved apnea/hypopnea index (AHI) scores more than oral appliances, CPAP users also showed significantly worse compliance with their devices.

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator surgery. Findings: The physician reviewer found that the patienthas a history of obstructive sleep apnea (OSA). He was treated with continuous positive airway pressure (CPAP) but he became intolerant to the therapy. The patient reported daytime somnolence. The patient’s provider recommended a surgical implantation of hypoglossal nerve stimulator. The Health Plan denied the requested services as investigational for the treatment of this patient. The hypoglossal nerve stimulator can be an effective therapy for certain patients diagnosed with OSA. However, in this patient’s case, the procedure is not likely to be superior to other methods of treatment for his medical condition.

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 Hypoglossal Nerve Stimulator, then check the rights and deadlines that apply to your plan.