Post#17 Sleep Studies: How to obtain rapid Authorization for Obstructive Sleep Apnea testing.  - Part 2


Home sleep testing (HST) represents an easy, accurate, and less costly way to diagnose OSA but not all patients are appropriate for home testing.  Patients with certain co-morbid conditions should NOT have a home test and thus may be a candidate for facility testing.  These conditions fall into three categories: sleep conditions, medical conditions or other circumstances.   It only takes one of these conditions to meet the criteria for a facility PSG. 

The sleep conditions were outlined in the first Sleep blog (Post#16)

Medical conditions
•    Neurological: Parkinson’s disease, a recent (3 mos.) stroke with residual deficits, epilepsy with active seizures, Spina Bifida, ALS, muscular dystrophy. 
•    Other medical conditions: 
♣    Congestive heart failure: class III or IV or LVEF < 45%
♣    Chronic Obstructive Pulmonary disease (severe, according to objective criteria)
♣    Chronic daily opioid use
♣    Chronic severe insomnia
♣    Note: sleep testing (home or facility) should only be performed when patients are stable, not during an acute relapse of CHF or COPD or recent hospitalization or steroid use. 
Other circumstances
•    Obesity: any patient with a BMI > 35 and unable to lie flat in bed OR     BMI > 45 should not have an HST.
•    Mechanical barriers: patients with visual, mobility, mentation, comprehension or dexterity limitations should not have a home test
•    Age limits: Home testing should not be used in children (under age 18). There is no upper age limit that contraindicates home testing but many patients over 75 have dexterity, mentation, or comprehension issues. 
•    Prior inconclusive HST: If home testing has been done and is negative, inconclusive, or technically inadequate facility testing can be approved.
•    If patients have strong suspicion of having OSA (e.g. has history of witnessed apnea, daytime somnolence, or loud irregular snoring) but patient-performed questionnaire shows low pre-test probability. 
•    After sleep apnea surgery or treatment: Home sleep testing (HST) can be used before or after any OSA surgery (if a study is needed).   HST can be used after weight loss to assess continued need for continued PAP treatment.  Patients with suspected narcolepsy may be candidates for PSG but should also be considered for HST or Multiple Sleep Latency Testing first. 

If you have determined that your patient may have a HST as an alternative to PSG, prior authorization may not be need for many insurance companies. The majority of insurance companies with sleep prior authorization programs do not require approval for home testing.  Your sleep lab vendor should be able to tell you if HST requires prior authorization.  

Q. Do all patients require a sleep questionnaire before being approved for a sleep study? 
A. No.  If a sleep partner has given history of witnessing apnea, questionnaire is not required. Also, if the patient has previously been diagnosed with OSA, sleep questionnaire is not required.

Q. If patients have OSA, won’t they still need an overnight facility study to determine their CPAP settings?   
A. Not necessarily.  A new approach, using AUTO-PAP with variable pressure, is now available, and many patients with OSA diagnosed by home testing could be given AUTO-PAP to see if symptoms resolve. Prior authorization is not usually required for AUTO-PAP.  

Q. Sleep specialists will often convert a PSG into a split-night study, and perform titration for cPAP in the second half of the night if the first half is strongly positive for OSA. Wouldn’t this justify approval of a facility test instead of a home test?  
A. Not necessarily.  A split-night study may be no better than an HST followed by AUTO-PAP in many patients. 

Lesson #17: When suspecting obstructive sleep apnea, an H & P followed by a sleep questionnaire is usually required to determine whether your patient should have a home or a facility sleep testing.  This is not only required for authorization, it is also common sense and follows evidence-based sleep guidelines formulated by national sleep societies.