home sleep study not a medically necessary

[holdensjane]

my dad has sleep apnea. the doctors office verified approval supposedly and set him up for a home sleep test. It was positive so they sent him to a sleep lab, which insurance paid for. but now they're saying the home sleep test is not medically necessary because the doctor's reason for it basically said "possible sleep apnea". its the weekend so we will call the doctor's office on monday, but in the meantime, the home study people keep sending us bills.

Any advice on appeals or what i should do? what would you do?

[teknomom]

Good luck with this. I have been billed in error for some things and it turned out to be a coding error or misunderstanding of my insurance. It's good to contact the company that is billing you and also the doctor to make sure he understands what your insurance requires as a diagnosis in order to pay for the study. Your insurance company may be able to help also. They can misread the doctors diagnosis coding or the company's billing coding. Every step of the way it comes down to a human being writing (or typing) something and another human being reading it. I hope it is just an error and you can get it corrected.

[Janknitz]

Assuming your dad is on Medicare, you will find the number for the local "SHIP" or HICAP (California) number on the back of his 2012 Medicare and You book or on the http://www.medicare.gov website. Call that number for FREE assistance in appealing the denial. Most likely the at home testing provider and/or your doctor did not code it correctly. In addition, since it was only a screening and not a test, it may not be covered by Medicare but the provider should have advised you of that in advance.

[mstevens]

This needs to be appealed by the physician's office. Be aware, though, that Medicare doesn't pay to rule anything out (!!), so wording is paramount.

Home sleep studies are worth about what you see here - little to nothing - because they're limited in data channels and have to be confirmed with a lab study most of the time. That may be another reason insurance doesn't want to cover it.

[cpaptex]

If wording is the key, perhaps your Dr. can say "symptoms consistant with Sleep Apnea, Sleep Assessment required to validate Dx". I've had Insurance, not Medicare, verbage that had to be cleared up to provide coverage. Today, I learned to confirm coverage first.

[jamiswolf]

Mstevens wrote: This needs to be appealed by the physician's office. Be aware, though, that Medicare doesn't pay to rule anything out (!!), so wording is paramount.

Doctors order lab tests and x-rays all the time to rule something out...and Medicare doesn't deny it.

Mstevens wrote: Home sleep studies are worth about what you see here - little to nothing - because they're limited in data channels and have to be confirmed with a lab study most of the time. That may be another reason insurance doesn't want to cover it.

Again...an inaccuracy. Home sleep studies are valid to diagnose and to determine the severity of sleep apnea. You just can't do a titration. A home study followed up with a machine titration using an apap is very common and covered by most insurances including Medicare.

The difficulty with home studies is when the results are negative. Then a follow up lab study is needed.

Jamis

[mstevens]

Doctors order lab tests and x-rays all the time to rule something out...and Medicare doesn't deny it.

I order tests all day every day that I work, largely to rule things out. Medicare denies payment for tests all the time, particularly if ordered to rule something out. What this means in practice is that I can't order anything to rule out, say, hypothyroidism (which is, of course, the real reason I'm ordering it) but rather just give the diagnosis as "hypothyroidism". Then, if the test is negative, I just say "Hm. Guess I was wrong." It's a stupid bit of pretend, but the precise words used in documenting matter in terms of whether something is covered or not.

Home sleep studies are valid to diagnose and to determine the severity of sleep apnea. You just can't do a titration. A home study followed up with a machine titration using an apap is very common and covered by most insurances including Medicare.

The difficulty with home studies is when the results are negative. Then a follow up lab study is needed.

Current home studies are next to worthless in diagnosing anything other than OSA. They provide significantly fewer data channels than in-lab PSG. Ruling in OSA does not rule out other sleep disorders which may not be caught by a home study. In my opinion, most patients who have a home study will eventually need an in-lab study, so why not just start with that?

In my neck of the woods, what you describe is not only not "very common", it's not even possible since there's nobody that offers home studies in my state.

[jamiswolf]

Mstevens wrote: Current home studies are next to worthless in diagnosing anything other than OSA.

So can I read into this statement that they are valuable for diagnosing OSA? And a home study set-up uses a chest strap to determine respiratory effort...so it CAN differentiate between an obstructive apnea and a clear airway apnea.

Mstevens wrote: In my opinion, most patients who have a home study will eventually need an in-lab study, so why not just start with that?

There are several good reasons. Primary is that most rural areas don't have a sleep lab available. Also, I actually feel there's some validity to having the patient sleep in their own home and their own bed. How many times do lab studies fail because the patient can't sleep in such a foreign environment? And for victims of sexual assault...a home study might be the only option. Few woman rape or abuse survivors could handle the stress of a lab sleep study.

Edit: And last but not least...people w/o insurance may only be able to afford a home study.

Mstevens wrote: In my neck of the woods, what you describe is not only not "very common", it's not even possible since there's nobody that offers home studies in my state.

Increasingly there are national companies that mail home sleep study equipment to patients and then will mail results to local physicians. Home sleep studies are on the rise.

To Holdenjane: Was the second sleep study done in a lab for titration or was it to confirm the diagnosis? This might be a crucial point in coverage.
Jamis

[NightMonkey]

In my opinion, most patients who have a home study will eventually need an in-lab study, so why not just start with that?

I will give you one example of why home studies are valuable and will be used more and more. My doctor required me to have an in-lab diagnosis night. It was very obvious that I had severe OSA and as expected no other health disorders were detected.

Then I had to go back for a second study to do the titration. They took the entire night and did not get a good script (I later adjusted my pressure using the Encore software and then started getting good results.)

A home sleep study the first night would have saved all the cost of a technician and lab for eight hours. It would also have saved me travel time to and from the lab and a lot of aggravation.

My current sleep doc has the home study equipment and keeps it in constant use. The practice only charges for an office visit to prescribe the study - they do not charge for the equipment or the study. They call you with the results and to schedule a titration study if needed. That is quite a difference in cost, time, and effort as compared to what is typically charged for an in-lab study!

Home sleep studies are not going away. They will become universal for suspected OSA cases. Medicare will begin pushing it. Private insurance companies will begin pushing it.

I believe about 95% of patients with sleep disorders have simple OSA. We should use the small, cheap home studies to catch this 95%. The 5% that test negative but still have significant symptoms can be run through a night in the lab. Or if the doctor has good evidence to suggest something besides or in addition to OSA he can start with the lab study.

[jnk]

I don't know if the rules have changed, but . . .

Q & A
Q: What is the Medicare payment for home sleep tests?
Payment for home sleep tests has not been established by
Medicare at the national level, therefore payment will be
determined by local Medicare contractors.

Q: What other restrictions should physicians be
aware of?
Medicare and some commercial payors require that home
sleep tests be interpreted by physicians who are boardcertified
in sleep and/or members of an accredited sleep
center. Check local policies for further details.

Q: Which commercial payors cover home sleep testing?
Currently, Aetna, Anthem, Cigna, Humana and United cover
home sleep testing in some form with varying restrictions.
Payors change policies frequently and may vary coverage
by region.

Q: Can a patient be sent to a lab for titration following
a home sleep test?
There are no current Medicare restrictions on referring
patients based on medical necessity as established by a
physician to undergo titration in a facility-based setting.

Q: Can a DME conduct a home sleep test?
The Medicare DME MAC LCD policies specifically state that
a DME supplier cannot be involved in any aspect of a home
sleep test, including, but not limited to, delivery and/or pickup
of the device.

http://www.resmed.com/us/documents/1013 ... ealink.pdf

[Janknitz]

On the contrary, there ARE Medicare approved home PSG studies available. They are multi-channel units and their accuracy, for what they measure, is every bit as good as an in lab study, in some cases more because the individual gets to sleep in his or her own bed and sleeping conditions. They aren't designed for complex apneas and sleep movement disorders, but since most people have garden variety OSA, they are fine for that.

An example of a home sleep study unit is the Itamar Watch Pat.

Kaiser, for example, does home studies exclusively in my region. Kaiser has a vested interest in diagnosing and treating OSA, because it is preventative and may avoid some of the medical complications of long term untreated OSA. They also do home titrations.

I'm personally a big fan of home testing and titration. I NEVER would have agreed to do one, much less two overnight sleep lab studies and I'd still be undiagnosed and treated to this day. Furthermore, I feel like my titration was pretty accurate, because it was done over several nights (rather than a single night "snapshot") in my own bed and sleeping conditions. This makes a LOT of sense, provided there is adequate patient education on mask fitting and machine use.

Sleep labs are appropriate for more complex issues, but if the issue is straightforward OSA, home testing and titration makes a lot of sense!

[jnk]

Other than in certain exceptional circumstances, home sleep tests are a total waste of time, medically speaking, in my opinion as a patient. They are an economic tool, not a medical tool. And not a very good economic tool, at that.

After all, if all you are doing is attempting to confirm an obvious diagnosis of OSA for someone with a low likelihood of having other sleep issues (which is the only circumstance in which AASM recommends home sleep tests, as I understand it), why "test" at all? Response to treatment from a one-month rental will confirm the diagnosis more efficiently and more cheaply in that sort of patient anyway, if we're talking medicine, not insurance.

Question: When trying out the treatment is harmless and costs less than the test, why do the test at all? Answer: To get insurance to pay for the treatment.

The best help to the patient would be EITHER to get them on treatment as soon as possible without wasting time on any test OR to get them the test that would screen for other sleep disorders, an attended PSG. HSTs only get in the way of either best-for-patient option, and that is because of financial considerations, not medical ones.

[mstevens]

And a home study set-up uses a chest strap to determine respiratory effort...so it CAN differentiate between an obstructive apnea and a clear airway apnea.

There are many sleep disorders besides breathing-related ones.

most rural areas don't have a sleep lab available.

I'm in a very rural area and there are several labs within a few hours' drive.

How many times do lab studies fail because the patient can't sleep in such a foreign environment?

Surprisingly few.

Few woman rape or abuse survivors could handle the stress of a lab sleep study.

Why single out women? They're tougher than many guys give them credit for. There are plenty of men who are rape or abuse survivors, in any event. All of my patients with such histories have been able to get good studies done at the lab with enough preparation ahead of time.

people w/o insurance may only be able to afford a home study.

Sure, but in those cases it's immaterial whether Medicare will pay for the home study. Just because something is all you can afford doesn't mean it's adequate or a good idea. Lots of people take subtherapeutic medication doses because they can't afford the full dose, but some of them would be better off not taking it at all unless they can take the full amount.

there are national companies that mail home sleep study equipment to patients and then will mail results to local physicians.

We then depend on patients with varying degrees of mechanical aptitude, dexterity, or even reading skill to be able to use the equipment properly.

[BlackSpinner]

I had a home sleep study. The lab that handed them out was very good at training how to wear them and had a detailed check list with it. In fact they were much better then the DME.
Most people here go through a home sleep study to diagnose the garden variety OSA. If you fail it you get a full in house study. I also got a home titration study and I am happy with that too.
I am also happy that my government is not wasting my tax money on lab sleep studies for over 75% of people diagnosed with simple OSA. I would rather have them spend that money on cancer surgeries and joint replacements

[jnk]

The American Academy of Sleep Medicine (AASM) has published suggested guidelines for the use of HST in the diagnosis of OSA. They recommend that HST be used only in the context of a comprehensive sleep evaluation and for the following patients:

Patients with a high pre-test probability of moderate to severe OSA.

Patients with no significant co-morbid medical condition. Examples of co-morbid conditions include moderate-severe pulmonary diseases (cystic fibrosis, pulmonary fibrosis, active asthma, COPD), congestive heart failure and neuromuscular diseases (ALS, multiple sclerosis, Parkinson’s disease).

Patients suspected of having no co-morbid sleep disorder other than OSA.

Patients unable to be studied in a sleep laboratory.

To monitor response to non-CPAP treatments after the diagnosis has already been made.

. . . A useful formula for estimating patients at high risk for moderate to severe OSA:
Patients at high risk for moderate to severe OSA have symptoms of OSA, excessive daytime sleepiness and an Adjusted Neck Circumference > 43 cm (17 inches)
Symptoms of OSA = snoring, stopping breathing episodes or complaints of daytime sleepiness
Presence of excessive daytime sleepiness = Epworth sleepiness scale >10
Adjusted neck circumference = neck circumference + 4 cm (if hypertension present) + 3 cm (if habitual snorer) + 3 cm (if reported to choke or gasp most nights)

. . . HST is used only to look for obstructive sleep apnea. Only 4-5 channels of physiologic data regarding respiration are obtained, as opposed to 14 channels during in-lab polysomnography.

. . . Information on sleep stages and EEG is not obtained with HST. As a result, HST may underestimate the severity of OSA. If the HST is negative in a patient suspected of having OSA, the patient should have an in-lab PSG for confirmation.

http://www.sleephealth.com/services-hom ... er-faq.htm

So the trick is for every doctor simply to suspect that a patient could have "a co-morbid sleep disorder other than OSA," as I highlighted in red above. I believe that every patient should be suspect for that. Therefore every patient should have a PSG, IF they get tested. My contention is that a physician should be allowed to diagnose based on observation alone, as far as those with a high probability of moderate to severe OSA. The only reason he can't is that payers want proof of response to treatment that is not "merely" subjective observations of doc and patient. THAT is what is being paid for, the proof, not the treatment itself.

Once you factor in the retests, the number of patients missed in the screening and who go on to more serious problems, the number who have to have a PSG anyway so that now two tests have to be paid for instead of one, the mailing/transporting of the equipment, the reading by a certified doc anyway, etc, I don't think there is any real cost savings over the long-haul either, myself.