Polysomnography denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a sleep study. In this case, the records indicate the presence of daytime fatigue, accompanied by snoring and hypersomnia, which was significant enough to contribute to a motor vehicle accident. Despite the absence of an elevated body mass index (BMI) or nocturnal hypoxemia, the records highlight the coexistence of insomnia and attention deficit hyperactivity disorder (ADHD), which are both potentially linked to undiagnosed sleep apnea. Researcherswith ADHD, such as difficulties concentrating, ineffective planning, and restlessness. The authors further note that the treatment of OSA is associated with an improvement in ADHD symptoms. As with ADHD, insomnia and OSA may also share overlapping symptoms.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study test for evaluation of her history of daytime somnolence. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient presented with a clinical presentation that was suggestive of a sleep-related breathing disorder. In this case, the patient had significant malocclusion, dental crowding and a large tongue. Malocclusion has been linked to sleep-disordered breathing in recent publications. The presence of an enlarged tongue is also considered to be a potential risk factor for sleep-disordered breathing. There is sufficient evidence that correction of these anatomical abnormalities can lead to improvement/resolution in sleep-disordered breathing.

Where the denial was upheld

An enrollee has requested authorization and coverage for an in-center polysomnography test. American Academy of Sleep Medicine (AASM) guidelines recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adult patients who present with signs and symptoms that indicate an increased risk of moderate to severe OSA. These guidelines recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography should then be performed for the diagnosis of OSA.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for continuous positive airway pressure (CPAP) equipment and/or the requested sleep study (CPT code 95810). Unlike the treatment of obstructive sleep apnea (OSA) in adults, the treatment of OSA in children is approached comprehensively, considering their unique needs and their developing physical characteristics. According to the medical literature, diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. An in-lab diagnostic polysomnogram (PSG) is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.

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