Criteria for sleep studies for Medicare and private insurersThis is a common question from practices treating patients suffering from snoring, obstructive sleep apnea, and other types of sleep disordered breathing & sleep disorders.
The quick answer: the more recent the sleep study, the better!
The longer answer: some insurers will prefer that when a treatment that is being performed based on a sleep study, that the sleep study be no more than 12 months old, some insurers prefer 2-3 years, some still state 5 years, and some will not have a written guideline that specifies a time frame for age of sleep study!
For Medicare: the sleep study must be no older than 12 months, according to the Local Coverage Article: Standard Documentation Requirements (SDR) for All Claims Submitted to DME MACs (A55426), in which it is stated "Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy".
It is important to look at this question from both a clinical stand point as well as a medical insurance standpoint.
First – from a medical insurance standpoint – you can check the insurer’s medical policy for Diagnosis and Treatment of Obstructive Sleep Apnea to see if there is a time frame specified for age of sleep studies or not (many do not).
Second – from a clinical standpoint – it is extremely important to keep in mind: no matter what the insurers stance is on sleep studies, and no matter what coverage is offered under the patient’s medical plan – our main concern should be WHAT IS BEST FOR THE PATIENT?
Ensuring up-to-date evaluation and diagnosis takes place will always not only benefit the patient, but you as the health professional as well.
Say a patient presents to your office with a sleep study performed 4 years ago. You check their insurers medical policy, and studies up to 5 years of age are accepted for coverage of oral appliance therapy for OSA.
Now, 4 years ago, this patient’s study showed an AHI of 11 – mild obstructive sleep apnea. So, you go ahead and make & seat the appliance for the patient, send them for their efficacy follow up study….and the AHI now shows to be 13, with the appliance in place.
What Happened?!?! Is the appliance making the patient’s OSA worse?
Possibly not! However, we won’t know until the patient has a new baseline sleep study performed without the oral appliance in place!
Here’s what happened:
This patient went through the sleep study 4 years ago and AHI was 11. In the last 4 years, the patient gained 20 pounds due to stress at work and a recent divorce, has started taking blood pressure medication, and drinking heavily at night accompanied by sleeping pills. So, the patient did a new baseline sleep study, and found his AHI has risen to 29. So the appliance actually did help reduce the patient’s AHI from 29 to 13, but we would have never known without a fresh baseline sleep study to confirm how severe the patient’s OSA current is. With a little further calibration, counseling the patient to get him away from the depressants before bedtime, and maybe a little positional therapy to go along with it, this patient will be sleeping better than he has in years.
So – working with old sleep studies results can actually harm your positive treatment results by making them look, well, not so positive! This can not only send a negative (and untrue) message not only to your patients, but your referring health professionals as well.
Also – some insurers may state a time frame, as well as add the guideline that if there have been any significant changes in the patient’s health history since the date of their last history, that deems medical necessity for a new sleep study to be performed to get a fresh baseline AHI.