Sleep Study denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a sleep study with or without an esophageal pressure monitoring (PES) test.PES has shown benefit for patients with no witnessed respiratory pauses during sleep with excessive sleepiness, negative prior sleep study as well as patients with persistent sleepiness and suspected reflux. Although PES can strengthen treatment to improve clinical outcomes for the investigation of the pathophysiology of respiratory function, it is typically used in the context of suspected respiratory failure. A study found that a polysomnogram study is sufficient for the evaluation of patients with excessive sleepiness. In addition, the consideration of pulse oximetry in a sleep workup can be considered if there is suspicion of airway resistance.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for a sleep study for evaluation of the enrollee who has a history of epilepsy and encephalitis. Findings: The physician reviewer found that there is sufficient support in the documentation and in the medical literature for the services at issue in this clinical setting. This patient has been diagnosed with Hashimoto’s encephalopathy, a poorly understood clinical entity. However, what is known about this disease complex is that the resultant encephalopathy is associated with sleep abnormalities in over one out of two patients with this treatable syndrome. Since this patient has encephalopathy, with diffuse evidence of brain dysfunction, it is also likely that the reticular activating system is dysfunctional.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study provided in a facility setting. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollee’s obstructive sleep apnea and snoring.At issue in this case is whether the requested sleep study; provided in a facility setting was medically necessary for treatment of the enrollee’s medical condition.Current literature indicates that there has been a shift from the provision of services in the laboratory setting to the ambulatory setting. Unattended and attended testing has been shown to yield equivalent outcomes to laboratory testing in at least two randomized trials.In this case the patient had an elevated body mass index, a large neck and complaints of snoring which raise the concern of obstructive sleep apnea (OSA).

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study performed on 8/29/16. The Health Plan has denied this request indicating that the requested procedure was not medically necessary for treatment of the enrollee’s obstructive sleep apnea.At issue in this case is whether the requested sleep study performed on 8/29/16, was medically necessary for treatment of the enrollee’s medical condition.In this case, the patient was noted to have had a problem with sleep, specifically sleep disordered breathing. However, in this case the patient is noted to have undergone diagnostic sleep testing in 2011. That study reportedly led to a diagnosis of UARS. However, the patient's AHI was noted to have been 20.

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