Inspire HGNS denied as duplicate or overlapping therapy by Humana?

Humana'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 Humana Denies Inspire HGNS as Duplicate Therapy

Humana may issue a duplicate-therapy denial when its records show you are already receiving another treatment for obstructive sleep apnea (OSA) — most commonly CPAP, BiPAP, or an oral appliance — and the plan concludes that adding a hypoglossal nerve stimulation (HGNS) implant would duplicate an existing covered therapy. This logic is flawed in many cases, and the denial is frequently reversed on appeal.

The core counter-argument is that Inspire HGNS is not a supplement to positive airway pressure (PAP) therapy — it is a prescribed alternative for patients who cannot tolerate or adequately use PAP. These are distinct treatment modalities with distinct mechanisms, patient populations, and clinical indications. The FDA-approved labeling for the Inspire system specifies patient selection criteria; if your prescriber determined that PAP therapy is inadequate or not tolerated, the two treatments are not duplicates — they address the same condition by different means because the first-line approach failed.

## Federal Appeal Rights

You have federally protected appeal rights regardless of your plan type:

• ACA §2719 / ERISA §503: Most employer and marketplace plans must provide at least one internal appeal and, if denied, access to an independent external review.
• External review window: You generally have approximately four months from receipt of a final internal denial to request external review. Check your denial letter for the exact deadline — do not miss it.
• Expedited review: If your condition is urgent, you may request an expedited internal or external review, often decided within days.

## What to Gather

1. Diagnosis documentation — sleep study (polysomnography) confirming OSA diagnosis and severity classification from your sleep specialist. 2. PAP failure history — objective download data from your PAP device showing inadequate usage or adherence, plus chart notes documenting symptomatic failure, intolerance, or contraindication. Include dates and duration of PAP trials. 3. Clinical severity — chart notes documenting the impact of untreated or inadequately treated OSA on your health, including any related comorbidities. 4. Prescriber letter of medical necessity — a detailed letter from your surgeon or sleep physician explaining why HGNS is a non-duplicative, medically necessary alternative, not a supplement, to prior therapy. 5. Humana's own coverage policy — download Humana's current published coverage determination for hypoglossal nerve stimulation from humana.com. Copy each listed coverage criterion verbatim.

## Criteria-Mapping Structure

Organize your appeal with a two-column table:

| Humana Coverage Criterion (exact text from policy) | Evidence in Your Chart Meeting That Criterion | |---|---| | [Copy criterion 1 from the policy] | [Specific chart note, date, and finding] | | [Copy criterion 2 from the policy] | [Specific chart note, date, and finding] |

Close your appeal letter by stating plainly: the prior therapy and the requested therapy are not duplicative because the prescriber has documented that PAP therapy was inadequate, and the applicable guideline organizations (including the American Academy of Sleep Medicine) recognize HGNS as a distinct evidence-based treatment for appropriate patients. Request that Humana provide its specific clinical basis for concluding duplication exists, as required under ERISA full-and-fair review.