Inspire HGNS denied for failing step therapy 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 Under "Step Therapy" — and How to Appeal

Aetna's coverage policy for Inspire Upper Airway Stimulation (hypoglossal nerve stimulation, HGNS) requires that patients first demonstrate an adequate trial of, and inadequate response to or intolerance of, CPAP (continuous positive airway pressure) therapy before the insurer will authorize the device. This is classic step therapy: the insurer requires you to "step through" a less expensive or less invasive treatment first. The denial is not a statement that Inspire is never covered — it is a statement that Aetna needs proof the required prior step was completed. This type of denial is among the most winnable on appeal, because the documentation almost always exists in your chart.

## Federal Appeal Framework

For ERISA employer plans, ERISA §503 guarantees full-and-fair internal review. ACA §2719 provides an independent external review right after internal appeals are exhausted. The external review window is approximately four months from your final internal denial letter. Many states have also enacted step-therapy override laws requiring insurers to grant exceptions when a patient has already tried and failed the required prior step — check whether your state has such a law, as it may apply to state-regulated plans.

## Your Concrete Appeal Steps

1. Document the CPAP trial completely — gather all records showing when CPAP was prescribed, the duration of the trial, any adherence download data, and your documented response (or lack thereof). 2. Establish CPAP intolerance or inadequate response — obtain a letter from your sleep physician describing the specific reasons CPAP was not adequate for your case (side effects, anatomical factors, adherence failure despite intervention, residual apneas). Be specific about dates and outcomes. 3. Confirm you meet Aetna's clinical criteria — obtain Aetna's current coverage policy bulletin for Inspire HGNS from aetna.com/cpb. Each eligibility criterion should be addressed one-by-one with supporting documentation from your chart. 4. File the internal appeal with your sleep study, CPAP trial records, and your prescriber's medical-necessity letter. 5. Invoke any applicable state step-therapy override law in your appeal letter, if your plan is state-regulated. 6. Escalate to external review if internal appeal fails.

## Documentation to Gather

• All sleep study reports (diagnostic and any titration studies)
• CPAP prescription and initiation date
• CPAP adherence data downloads with dates and usage hours
• Clinical notes documenting CPAP intolerance or failure with specific reasons and dates
• Prescriber's medical-necessity letter explicitly addressing each step-therapy requirement in Aetna's policy
• Any specialist referral notes from an ENT or sleep surgery program

## Criteria-Mapping Structure

Create a side-by-side table: Aetna policy requirement (exact quote) | Your documentation | Key fact. Copy each criterion verbatim from Aetna's clinical policy bulletin. For the CPAP step requirement, cite the exact dates of the CPAP trial and the clinical note documenting the outcome. Reviewers approve appeals faster when they do not have to search — make their job easy.