Is hypoglossal nerve stimulation medically indicated for a patient with severe obstructive sleep apnea (OSA) who has failed Continuous Positive Airway Pressure (CPAP) therapy?

Is Hypoglossal Nerve Stimulation Medically Indicated for This Patient?

No, hypoglossal nerve stimulation is NOT medically indicated for this patient because he lacks documented polysomnography (PSG) within 24 months of consultation, which is a mandatory criterion that cannot be substituted with home sleep testing (HST) alone.

Critical Missing Documentation

The patient underwent only a home sleep test (HST) on 11/14/2024, not a formal in-laboratory polysomnography 1. While the Aetna policy explicitly requires "a polysomnography (PSG) is performed within 24 months of first consultation for Inspire implant," this criterion remains unmet. The distinction is critical because:

• HST cannot reliably differentiate central from obstructive events with the same accuracy as attended PSG 1
• HST may underestimate AHI compared to PSG, particularly in patients with cardiac history (this patient has prior STEMI requiring cardiac stent) 1
• The policy language specifically states "polysomnography," not "sleep study" or "HST" 1

CPAP Intolerance Documentation Inadequacy

The medical record states the patient "tried CPAP for a few year(s)" and "failed CPAP therapy due to uncomfortable," but this does not meet the Aetna definition of either:

• CPAP failure: AHI >15 despite CPAP usage with objective download data 1
• CPAP intolerance: <4 hours per night, 5 nights per week, documented by objective compliance data 1

No objective CPAP compliance data (machine download reports showing hours of use, residual AHI, mask leak) are present in the submitted documentation. Subjective patient report of discomfort alone is insufficient 1, 2.

What Would Make This Case Approvable

To meet medical necessity criteria, the following documentation must be obtained:

1. In-laboratory attended polysomnography performed within 24 months of the consultation date, confirming:

   • AHI 15-100 events/hour 1
   • Central/mixed apneas <25% of total AHI 1
   • Adequate sleep architecture assessment 3

2. Objective CPAP compliance data from the patient's CPAP machine showing either:

   • Residual AHI >15 despite adequate usage (CPAP failure), OR
   • Usage <4 hours/night on ≥5 nights/week over minimum 1 month trial (CPAP intolerance) 1, 2

3. CPAP optimization attempts should be documented, including mask fitting trials, pressure adjustments, and treatment of nasal obstruction (patient has documented left septal deviation 76% obstructed and right nasal polyps) 1

Criteria That ARE Met

The patient does satisfy several important criteria:

• Age: 64 years old (≥18 required) 1
• BMI: 31.19 kg/m² (<40 required; some guidelines suggest <32 for optimal outcomes) 1, 4
• AHI range: 45.2 events/hour (within 15-100 range) 1
• Predominantly obstructive events: Central apnea 0% (<25% required) 1
• Anatomical candidacy: DISE on 10/24/2025 showed no complete concentric palatal collapse, 25% lateral wall/75% AP collapse, making him an anatomical candidate 1, 4
• Tonsil size: Grade 1+ tonsils (not 3-4 which would be exclusionary) 1

Clinical Context and Cardiovascular Considerations

This patient has significant cardiovascular disease (STEMI 06/2024 requiring cardiac stent, on dual antiplatelet therapy with aspirin and ticagrelor). Untreated severe OSA (AHI 45.2) substantially increases cardiovascular morbidity and mortality risk 2. However, this urgency does not override the requirement for proper diagnostic documentation before proceeding with surgical implantation.

The appropriate next step is to obtain formal PSG and objective CPAP compliance data before resubmitting for authorization. The patient's nasal obstruction (septal deviation, polyps) should also be addressed, as this may improve CPAP tolerance and could potentially be corrected during the same surgical encounter if HNS is ultimately approved 1, 4.

Common Pitfalls to Avoid

• Do not accept HST as equivalent to PSG for HNS candidacy, even if AHI values appear adequate 1
• Do not proceed based on subjective CPAP intolerance alone without objective compliance downloads 1, 2
• Do not overlook treatable anatomical barriers to CPAP (this patient's significant nasal obstruction may be contributing to CPAP intolerance) 4
• Do not assume all criteria are met simply because the surgeon states the patient "qualifies for Inspire" - payer criteria may differ from FDA approval criteria 1