Following on the heels of the billing and coding issues are the insurance carriers’ gross interference in the management of OSA/UARS patients through unwieldy and bureaucratic prior authorization schemes. Prior authorizations are a tricky matter because at first blush it would seem insurers have a legitimate objective to contain costs by serving as a gatekeeper regarding the types of sleep studies for which patients may be scheduled, such as home sleep tests (HST) or overnight polysomnography in the sleep lab (PSG). To be sure, straightforward cases of so-called classic sleep apnea with noticeable daytime sleepiness and minimal co-occurring health problems can be served well by the HST model of care, and therefore the HST is a reasonable starting point for clinical intervention.
The main problem arising from this model is that a huge proportion of sleep apnea cases, surprisingly or not, do not fit into a one-size-fits-all, straightforward presentation, because so many OSA/UARS patients suffer numerous co-occurring medical or psychiatric illnesses. Yet, among the insurance carriers, each of which develops their own guidelines for prior authorizations, there is a consistent tendency to write these rules in a very narrow framework, forcing nearly all patients into HST. As a good example, a patient with PTSD, severe claustrophobia, panic attacks and difficulty staying asleep through the night (sleep maintenance insomnia) would not be eligible per most insurance guidelines for anything but HST as the first step in evaluating OSA/UARS.
On the other hand, anyone with co-morbid cardiac disease of significant severity has a very good chance of receiving authorization for a PSG. Take a look at the following coverage policies regarding HST vs PSG from a prominent insurer:
Attended full-channel nocturnal polysomnography (NPSG) is [permissible] in patientswith suspected OSA and one or more of the following indications:
- Significant chronic pulmonary disease
- Progressive neuromuscular disease/neurodegenerative disorder [e.g.Parkinson’s disease, myotonic dystrophy, amyotrophic lateral sclerosis, multiple sclerosis with associated pulmonary disease, history of stroke with persistent neurological sequelae]
- Moderate to severe pulmonary hypertension
- Moderate to severe cardiac disease [e.g.congestive heart failure, uncontrolled tachyarrhythmia (fast heart rate) or bradyarrhythmia (slow heart rate)]
- Body mass index (BMI) >50
- Obesity Hypoventilation Syndrome
- Documented ongoing epileptic seizures in the presence of symptoms of sleep disorder
Attended full-channel nocturnal polysomnography (NPSG) is [also permissible] in patients without suspected OSA and one or more of the following indications:
- Severe chronic periodic limb movement disorder (PLMD)
- Restless leg syndrome (RLS) that has not responded to treatment
- Parasomnia with documented disruptive, violent or potentially injurious sleep behavior suspicious of rapid eye movement (REM) sleep behavior disorder (RBD)
- Narcolepsy, once other causes of excessive sleepiness have been ruled out
- History of central sleep apnea
- Patient is a child or adolescent (i.e. <18 years of age)
- Results of previous home sleep test (HST) were either:
- Indeterminate for suspected OSA or upper airway resistance syndrome; OR
- Documented as technically inadequate after 2-3 attempts/nights; OR
- Documented as patient’s lack of mobility or dexterity to use HST equipment safely at home; OR
- Cognitive impairment such that the patient is unable to perform a home sleep study
So what’s missing from this list? From our point of view, two specific and overlapping conditions should be included, insomnia patients and individuals with moderate to severe mental health problems. We recommend inclusion of these types of disorders, because these patients often suffer prominent UARS components to their sleep breathing disorders, or the erratic nature of their sleep patterns would not make HST an efficient approach to care.
One might argue the section above (Part II,G1,G2) on patient dexterity or cognitive impairment might account for some of these patients and permit them to proceed directly with PSG; but in the PTSD example just described, neither dexterity issues nor impairment issues would describe someone reporting claustrophobia. Or, in the case of the insomniac with suspected OSA/UARS, how can this individual predict the type of sleep pattern he or she will experience when using an HST device?
I am not trying to suggest that all such patients are incapable of completing an HST, but I am trying to show the gap here in which certain types of patients would be better suited to complete the PSG protocol, because it would more rapidly clarify the diagnosis of UARS, and it would introduce the patient to the realm of laboratory sleep medicine and thus prepare them more effectively for the full night titration study he or she is likely to require in the future. Again, not every insomniac or mental health patient needs the PSG option, but the insurance carriers appear to look at these types of patients with a great deal of skepticism, presuming they are such unlikely prospects to be suffering from OSA or UARS so why bother with consideration for the type of testing they require?
This gap in knowledge is exacerbated by a lack of attention to the prevalence of OSA/UARS in both these populations, insomniacs and psychiatric patients. To my knowledge, there has never been a major position paper from the American Academy of Sleep Medicine highlighting the need for a very high index of suspicion for OSA or UARS in these types of patients. To the contrary, the AASM still publishes a practice parameter declaring that sleep testing in insomniacs should not be conducted routinely. Yet, all the major research teams in the USA and around the globe are clearly demonstrating that treatment-seeking insomniacs run rates of sleep-disordered breathing anywhere from 60 to 90%, which certainly indicates a need for very frequent sleeping test in this population.
To my knowledge, there are no AASM practice parameters on the value of sleep testing in psychiatric patients. Ironically, the American Psychiatric Association has shown incredible diligence by rewriting its handbook of disorders (DSM-V) to indicate two dramatic changes in the way they want mental health professionals to evaluate sleep disorders in psychiatric patients. The first change was to finally recognize the older terminology “sleep disorders secondary to psychiatric disorders” was a highly biased pronouncement consistently (and erroneously) interpreted by psychiatrists and psychologists to mean a mental health disorder treatment would cure the patient’s sleep problems. While this potential may exist, we now know it is often irrelevant as most sleep disorders in psychiatric illness take on a life of their own and need independent treatment. The second change, derived from the first, was the aggressive push calling for extensive sleep disorders evaluations in psychiatric patients to look for physical or physiological sleep disorders such as sleep breathing or sleep movement conditions.
Both these changes occurred through influences of sleep specialists and their research on psychiatric patients. These experts assisted in writing the DSM-V handbook sections on sleep disorders, and earlier versions already suggested or implemented these changes. Unfortunately, this gap remains large, because neither the AASM nor sleep specialists as a whole are vigorously embracing this model of care to scrutinize mental health patients. The prior authorization labyrinth only adds to the confusion and erects more barriers that block efforts to intensively evaluate insomniacs and mental health patients.