UHC Prior auth denied because they can’t/won’t read

Looking for advice on how to get this diagnostic procedure approved.

I'm covered under a united healthcare plan through my job. I recently had a home sleep study through Lofta.com which diagnosed severe Obstructive Sleep Apnea and moderate Central Sleep Apnea. I then saw an in-network sleep medicine doctor locally, who ordered an in-lab sleep study with CPAP/ASV titration (CPT 95811). "POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND".

The prior auth was denied stating:

"We found that this request does not meet the following criteria: – You have a medical condition that would require a sleep test with an attendant watching… And we did not receive this information: – A reason why a home trial of a device to help keep your airway open when you sleep could not be done… Under your health plan, this sleep testing is not medically necessary for your condition. You may be eligible for home sleep testing… This determination is based on the following information: Sleep Studies Policy Number 2023T0334MM Effective Date October 1, 2023."

I found that policy here: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/sleep-studies.pdf

Which states : "Attended full-channel polysomnography is medically necessary following an appropriate clinical assessment either because OSA has been excluded, OSA has been adequately treated, or documented symptoms suggest one of the following conditions:… Central Sleep Apnea…"

It's like UHC didn't even read the documentation that was submitted, since I've already had a home sleep test and there is strong evidence of Central Sleep Apnea.

My provider requested a peer-to-peer call, but UHC told them this wasn't eligible for a peer to peer call, but couldn't explain why, and that they'd have to file an appeal. My provider filed an appeal, and included all of the same documentation as well as clarifications.

The appeal was denied, stating "You do not meet health plan rules. Your doctor stated that a sleep study which showed obstructive sleep apnea (OSA) with some central sleep apnea (CSA). We do not see sleep studies that show central sleep apnea, either on baseline study or as treatment emergent on treatment download data. The denial is upheld."

My provider again requested a peer-to-peer call, but was told that because they had filed an appeal, they couldn't have a peer-to-peer call.

I'm at a loss for what to do now, other than file for a 3rd party review.

submitted by /u/MaleficentHat1299
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