Inspire HGNS denied for missing prior authorization by UnitedHealthcare?

UnitedHealthcare'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 UnitedHealthcare Issues a Prior-Authorization Denial for Inspire HGNS

UnitedHealthcare requires prior authorization (PA) for Inspire hypoglossal nerve stimulation in virtually all plan types. A "prior-auth-required" denial means the procedure was performed or ordered without an approved PA on file, or the PA request was submitted but not approved before the service occurred. This is one of the most common and most correctable denial types for this device.

## Two Distinct Scenarios

If no PA was submitted before the service: This is a retrospective (after-the-fact) authorization request. Federal and state rules vary on whether retrospective PA is available, but many plans allow it for urgent or emergency situations, or when the ordering provider was unaware of the requirement. Document whether the ordering provider had any basis to believe PA was not required.

If a PA was submitted and denied: The denial letter should specify the reason for PA denial — this is where a substantive clinical appeal begins. If the PA was simply not processed in time, escalate as a failure of the insurer's timeliness obligations.

## Federal Appeal Rights

• Internal appeal (ACA §2719 / ERISA §503): You have the right to a full-and-fair internal review of any adverse benefit determination, including a PA denial. Submit within the timeframe on the denial letter.
• External review: After the internal process is exhausted, request independent external review under ACA §2719. The external reviewer's decision is binding. The external-review window is generally within four months of the final internal denial.
• Expedited review: Available when the patient's condition is urgent or when a course of treatment is in progress.

## Documentation to Gather

1. PA submission records: Obtain copies of the original PA request, including date submitted, submitting provider, and any acknowledgment from UHC. 2. PA denial notice: If a PA was denied, obtain the specific denial reason and the criteria UHC applied. 3. Diagnosis and severity documentation: Sleep study results, specialist evaluation, and chart notes establishing the clinical indication. 4. Prior treatment failure documentation: Records of PAP therapy attempts — dates, adherence data, clinical notes on failure or intolerance — as this is a standard PA criterion for Inspire. 5. Prescriber medical-necessity letter: The ordering surgeon and sleep specialist should document clinical rationale and address each criterion in UHC's published PA criteria.

## Criteria-Mapping Structure

Obtain UHC's current published prior-authorization criteria and medical policy for hypoglossal nerve stimulation, and the FDA-approved labeling. Map every PA criterion to a chart finding:

| PA Criterion (from UHC policy) | Supporting Documentation | |---|---| | [Copy each PA criterion verbatim] | [Specific chart evidence, date, and provider] |

If the denial was purely procedural (no PA submitted), the appeal should focus on good-cause arguments and prospective authorization going forward, while simultaneously correcting the billing pathway to ensure a proper PA is in place before any future service.