Inspire HGNS denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for inspire hgns are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Aetna Denied Inspire HGNS for "Prior Authorization Required" — and How to Respond

Inspire Upper Airway Stimulation (hypoglossal nerve stimulation, HGNS) is a high-cost, implantable Class III medical device, and Aetna routinely requires prior authorization (PA) before it will cover the implant procedure. A denial coded as "prior auth required" most commonly means one of three things: no PA was obtained before the procedure, the PA was requested but denied on clinical grounds before surgery, or the PA was approved but the claim was submitted with codes that do not match what was authorized. Each scenario calls for a different response.

## Federal Appeal Framework

For ERISA-covered employer plans, ERISA §503 and Department of Labor claim regulations (29 CFR 2560.503-1) guarantee you the right to a full-and-fair internal appeal. Under ACA §2719, if the internal appeal fails, you have the right to an independent external review. The external review window is generally four months from the final internal denial. Expedited review (decision within 72 hours) is available when the standard timeline threatens your health — for example, if you have already had the device implanted and are awaiting medically necessary activation or follow-up.

## Your Concrete Appeal Steps

1. Determine the specific reason PA was not in place — was it never requested, denied, or mismatched on the claim? Your explanation of benefits (EOB) and the provider's billing records will clarify this. 2. If PA was never sought, work with your surgeon's office to submit a retroactive authorization request with full clinical documentation, then appeal the claim denial simultaneously. 3. If PA was sought and denied clinically, your appeal is a medical-necessity appeal (see the medical-necessity guide). File the internal appeal with your sleep study, CPAP-intolerance documentation, and your prescriber's medical-necessity letter. 4. If PA was approved but codes mismatched, have your surgeon's billing team correct the claim and resubmit; attach the original PA approval letter. 5. Escalate to external review if internal appeals fail.

## Documentation to Gather

• The original PA approval or denial letter (if one was issued)
• Sleep study report confirming diagnosis and severity
• Records documenting CPAP trial duration and outcomes (with dates)
• Prescriber's letter of medical necessity explaining why Inspire HGNS is appropriate for your specific case
• Surgeon's operative report and device implant records
• Itemized claim and EOB showing the codes submitted

## Criteria-Mapping Structure

Obtain Aetna's current coverage and prior-authorization policy for Inspire HGNS from aetna.com/cpb. Create a table mapping each PA criterion verbatim to the corresponding document in your record. For example: if the policy requires documentation of CPAP intolerance of a specified duration, identify the exact chart note or sleep study that records that trial. Precise, one-to-one mapping is the single most effective tool in overturning a PA-based denial.