Uvulopalatopharyngoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 12-year-old female with a history of sleep apnea. She has a prior history of tonsillectomy and adenoidectomy. She presented to her otolaryngologist with symptoms consistent with obstructive sleep apnea. A sleep study in September 2003 revealed a respiratory disturbance index (RDI) of 5.7 and lowest oxygen desaturation of 93%. This was interpreted at a sleep disorder clinic as mild obstructive sleep apnea. The patient was fitted with a BiPAP and had marked improvement in her symptomatology as documented by her otolaryngologist in May 2004. The patient had been compliant with BiPAP use. The patient then underwent spinal fusion surgery for severe scoliosis. The patient’s otolaryngologist has documented that the patient has become intolerant of CPAP/BiPAP. He has requested authorization for uvulopalatopharyngoplasty and partial glossectomy with radiofrequency.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for uvulopalatopharyngoplasty (UPPP) procedure. Although continuous positive airway pressure (CPAP) is considered first-line therapy for OSA, it is also associated with a 25-50% non-adherence rate. This patient is considered non-adherent as he has been unable to tolerate CPAP. One meta-analysis found that objective and subjective sleep-related outcomes improved significantly after UPPP for at least 34 months postoperatively (He, et al.). A systematic review found that CPAP non-adherence rates could be as high as 33% in many CPAP clinical trials, with a likely reduction in clinically meaningful benefit (Rotenberg, et al.).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgery of the upper part of the throat for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has been diagnosed with mild obstructive sleep apnea as well as nasal congestion. Physical examination revealed septal deviation, turbinate hypertrophy, redundant soft palate and elongated uvula. Polysomnography demonstrated an AHI of 6.0 and oxygen saturation nadir of 73%. Nasonex has been used for nasal congestion. The records do not document that prior treatment has been instituted for sleep apnea. CPT code 30465 is for repair of vestibular stenosis, which is most commonly done with placement of spreader grafts.

A 30-year-old male enrollee has requested uvulopalatopharyngoplasty (UPPP), removal of tonsils, septoplasty and resection of the inferior turbinates for treatment of his medical condition. Findings: The physician reviewer found that in this patient’s case, polysomnography performed on the date indicated showed evidence of obstructive sleep apnea. Follow-up titration of continuous positive airway pressure was performed and a maximum pressure of 16 cm of water was found to alleviate symptoms of obstruction. However, the submitted records do not include documentation of a length of trial of CPAP therapy nor of any effectiveness of the CPAP in reducing the symptoms of daytime somnolence. In order to establish the medical necessity of the UPPP, the medical record must document that the patient has undergone appropriate trial of CPAP therapy prior to surgical intervention.

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