Inspire HGNS denied for failing step therapy 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 Applies Step Therapy to Inspire HGNS

Step therapy — sometimes called "fail-first" — requires that a patient try and document failure of less costly or less invasive treatments before a higher-tier intervention will be approved. For Inspire HGNS, UnitedHealthcare's coverage policy typically requires documented prior experience with positive airway pressure (PAP) therapy before the device will be authorized. A step-therapy denial means the insurer's reviewer determined that the record does not sufficiently demonstrate the required prior treatment step — even if the patient genuinely tried and failed PAP therapy.

## Why This Denial Is Appealable

Step-therapy denials are among the most successfully overturned denial types, particularly when the prior therapy genuinely occurred but documentation was incomplete at the time of the original submission:

• Internal appeal (ACA §2719 / ERISA §503): Submit a full-and-fair internal appeal with complete prior-treatment documentation. Many step-therapy denials are reversed at the internal appeal stage when adequate records are provided.
• Step-therapy override laws: Many states have enacted step-therapy override statutes that require insurers to grant exceptions when the required step therapy is clinically contraindicated, was already tried, or would cause clinically significant harm. Check whether the patient's state law applies to this plan.
• External review: After exhausting the internal process, request independent external review under ACA §2719. The reviewer's decision is binding on UHC. The external-review request window is generally within four months of the final internal denial.
• Expedited review: Available for urgent or ongoing-treatment situations.

## Documentation to Gather

1. PAP therapy history: Detailed records of continuous positive airway pressure (CPAP), bi-level PAP, or other PAP modalities — including start dates, device download/adherence reports, and the duration of each attempt. 2. Documented failure or intolerance: Clinical notes from each treating provider explaining why PAP therapy was inadequate. "Intolerance" should be documented with the specific barriers the patient experienced, not just stated as a conclusion. 3. Prescriber attestation: The ordering sleep specialist should write a letter specifically addressing UHC's step-therapy criteria, explaining how the patient's prior treatment history satisfies — or why an exception is warranted from — each required step. 4. Contraindication or clinical override basis: If PAP therapy was clinically contraindicated rather than tried and failed, document the contraindication in the chart and have the prescriber address the applicable state step-therapy override criteria. 5. UHC's published step criteria: Obtain UHC's current medical policy for Inspire/hypoglossal nerve stimulation and list each step-therapy requirement explicitly in the appeal.

## Criteria-Mapping Structure

| Step-Therapy Requirement (from UHC policy) | Documented Evidence of Completion or Exception Basis | |---|---| | [Copy each step requirement verbatim] | [Specific dates, devices, adherence data, and clinical notes] |

Every required step must be addressed. If a step was completed but documentation was not submitted initially, include it now. If a step is being waived on clinical grounds, cite the specific override basis and supporting chart evidence.