Sleep Study Question....

[Randyp1234]

I've been lurking here for a while after doing a sleep study and having the tech give me a hint that I'll be doing a titration test next. Emailing with my doctor today he said that my results were mixed. He said that following Medicare criteria I did not have OSA but according to the pulmonology group's AHI criteria I do. At this time I do not know what my AHI number was. My question is - the night of the sleep study I slept terrible because of the strange environment and all the crap attached to me. I assume if I'm not sleeping deeply that my AHI would be less. Is this a correct assumption?

Thanks,

Randy

[GumbyCT]

I've been lurking here for a while after doing a sleep study and having the tech give me a hint that I'll be doing a titration test next. Emailing with my doctor today he said that my results were mixed. He said that following Medicare criteria I did not have OSA but according to the pulmonology group's AHI criteria I do. At this time I do not know what my AHI number was. My question is - the night of the sleep study I slept terrible because of the strange environment and all the crap attached to me. I assume if I'm not sleeping deeply that my AHI would be less. Is this a correct assumption?

Thanks,

Randy

Find out from your doc where you fell short of the Medicare requirements. At one time Medicare required that you sleep a minimum of 120 minutes during the diagnosis but I thought that was changed. So you need to find out what and why.

Will you be using Medicare or not?

Come back with that info about why you didn't meet the Medicare requirements.

[Randyp1234]

I've been lurking here for a while after doing a sleep study and having the tech give me a hint that I'll be doing a titration test next. Emailing with my doctor today he said that my results were mixed. He said that following Medicare criteria I did not have OSA but according to the pulmonology group's AHI criteria I do. At this time I do not know what my AHI number was. My question is - the night of the sleep study I slept terrible because of the strange environment and all the crap attached to me. I assume if I'm not sleeping deeply that my AHI would be less. Is this a correct assumption?

Thanks,

Randy

Find out from your doc where you feel short of the Medicare requirements. At one time Medicare required that you sleep a minimum of 120 minutes during the diagnosis but I thought that was changed. So you need to find out what and why.

Will you be using Medicare or not?

Come back with that info.

Nope - no Medicare for me but I wonder if it affect my health insurance willingness to cover a machine?

[Pugsy]

Some insurances will use Medicare criteria as their criteria. Some where I saw that Medicare has more than one way to qualify. So many AHI events or lesser number if accompanied by some of the usual sleep apnea symptoms..like excessive sleepiness. I will see if I can find the requirements.

If your insurance has certain criteria to meet the diagnosis for machine and equipment coverage and you don't meet criteria....then yes it will affect insurance paying for things.

[Randyp1234]

My main question here, though, is whether the fact that I wasn't sleeping well would impact the results of the test. If I was sleeping "deeper" is it likely that I'd have different AHI results? I felt I wasn't sleeping deep enough to even snore - although the tech did say I was in REM sleep just before she woke me.

[GumbyCT]

Nope - no Medicare for me but I wonder if it affect my health insurance willingness to cover a machine?

That, my friend, would be a question to ask your insurance.

[Pugsy]

Found this for Medicare criteria. Of course you would need to know if your insurance uses same criteria or something else. From on of Janknitz posts who knows a lot about insurance and medicare requirements.

INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.


I.An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met:


A.The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.


B.The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):
1.The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,

2.The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
a.Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

b.Hypertension, ischemic heart disease, or history of stroke.
C.The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.


II.An E0470 device is covered for those patients with OSA who meet criteria A-C above, in addition to criterion D


D.An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).

If E0470 is billed for a patient with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.

A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary.

If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test.

If an E0601 device has been used for more than 3 months and the patient is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin for use of the E0470.

Coverage, coding and documentation requirements for the use of the E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) and Policy Article (PA).

[robysue]

Emailing with my doctor today he said that my results were mixed. He said that following Medicare criteria I did not have OSA but according to the pulmonology group's AHI criteria I do.

I strongly suspect that your sleep lab uses the AASM Alternative Standard for scoring hypopneas instead of the AASM Recommended Standard. Medicare only recognizes the AASM Recommended standard for scoring hypopneas. I've written a bit about this from a patient's point of view in my blog entry Understanding the data in your sleep test report. I include links to two sites that discuss the two standards in much more detail and involve scholarly studies about how the different standards can affect a particular patient's diagnosis.

Technically I'm in this same boat, except that my first sleep doc never bothered to explain what my sleep test actually showed---he just said "You stop breathing 23.1 times an hour. You need CPAP. You need it now." It took me a long, long time to figure out (for myself with some help from folks here) that the large number of "Hypopneas with arousal" were scored under the Alternative Standard and that that was why they didn't show up in my official (Medicare) AHI (which was 3.5) but did show up in my RDI (which was 23.1). And it was the RDI that the diagnosis of moderate OSA was based on. My insurance company didn't quibble at all about covering the machine. It didn't quibble when I was switched to a bipap because I was having a terrible time tolerating CPAP due to aerophagia among other things: All that took was a letter of medical necessity from the doc's office briefly stating what we had done to try to make straight CPAP/APAP more tolerable for me and how it had not worked.

Sleep doc #2 did explain all this stuff about the "Hypopneas with arousal" to me. She also said that if I had been under Medicare and her patient at the time of diagnosis, Medicare would indeed have refused to cover a machine for me. She added that she would have fought to get me covered in that case. Whether it would have worked or not, I don't know.

So if your insurance company balks at covering the machine and you and your doc both believe you need the machine, make sure you know the appeals process and have the doc write the necessary letters of medical necessity.

[GumbyCT]

Emailing with my doctor today he said that my results were mixed. He said that following Medicare criteria I did not have OSA but according to the pulmonology group's AHI criteria I do

Maybe you didn't have enuff sleep time or enuff events. BUT Be careful he isn't setting you up for surgery.

Since Medicare frequently changes I like to check their site for updates. This seems to be a fairly recent update.

3. A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:
o AHI or RDI greater than or equal to 15 events per hour, or
o AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.
4. If the AHI or RDI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a 2-hour period.
5. The CMS is deleting the distinct requirements that an individual have moderate to severe OSA and that surgery is a likely alternative.

The full text can be found here -
https://www.cms.gov/transmittals/downloads/R86NCD.pdf

[Mary Z]

Randy, a night in the sleep lab is in no way a normal nights sleep. I have no idea whether staying in the lighter stages of sleep would cause less apneas.

[Randyp1234]

Randy, a night in the sleep lab is in no way a normal nights sleep.

You got that right!!

[jamiswolf]

Hi Randy,
I'm playing the devil's advocate here...

You sound like you really want to be on cpap and hope the numbers and such work out for you that way,

Believe me, it's a pain in the ass and any user in his right mind will agree.

Are you severely symptomatic? Why did you have the study?

If I could have slipped by under the numbers and didn't have to go on cpap...well I would have bought a bottle of Tequila and had a little party.

Were you sleeping on your back during the study?

Just information gathering...
Jamis

[Randyp1234]

Hi Randy,
I'm playing the devil's advocate here...

You sound like you really want to be on cpap and hope the numbers and such work out for you that way,

Believe me, it's a pain in the ass and any user in his right mind will agree.

Are you severely symptomatic? Why did you have the study?

If I could have slipped by under the numbers and didn't have to go on cpap...well I would have bought a bottle of Tequila and had a little party.

Were you sleeping on your back during the study?

Just information gathering...
Jamis

*Want* to have OSA and be on CPAP?? No....what I want it to be treated for OSA.

[jamiswolf]

jamiswolf wrote: I'm playing the devil's advocate here...

I thought the above made it clear I was being intentionally confrontational to make you think. Yet you got testy.

Randy wrote: ...what I want it to be treated for OSA.

OK, this is my point. You had one crappy sleep study with mixed results...yet you're convinced you have OSA.

I was just curious about why you felt that way.
Jamis

[robysue]

Randy wrote: ...what I want it to be treated for OSA.

OK, this is my point. You had one crappy sleep study with mixed results...yet you're convinced you have OSA.

I was just curious about why you felt that way.
Jamis

We really don't yet know what "mixed results" means since Randy has not posted detailed information from the sleep study.

Nor do I remember Randy posting whether he's actively suffering from major OSA symptoms such as excessive daytime sleepiness and fatigue or whether he's got co-morbid issues such as drug resistant HBP that might improve with CPAP.

And remember, while some of us were surprised or disappointed with our diagnosis because we really didn't have any significant daytime symptoms or co-morbid conditions, there are plenty of forum members who were very relieved to get the OSA diagnosis they were expecting. And why? Because it meant that something could be tried that might lead them to getting their life back. So Randy may well have multiple symptoms of OSA and multiple known risks for OSA and was surprised that the test results turned out to be "ambiguous" instead of a slam-dunk, you've got OSA and here's the CPAP.

And remember, Randy said: "my doctor today he said that my results were mixed. He said that following Medicare criteria I did not have OSA but according to the pulmonology group's AHI criteria I do. (emphasis added)"

Please note: Many certified sleep docs strongly believe that the Medicare criteria for diagnosing OSA are out of date and that the Medicare criteria minimize or ignore the importance of "hypopneas with arousal, but no desaturation" and RERAs. These are the docs who work with labs that tend to score hypops using the AASM Alternative Standard and/or RERAs; and to diagnose OSA they use the broader based RDI, which includes these "Alternative standard hypops" and RERAs, rather than the Medicare-approved AHI that only includes hypopneas that trigger desats of at least 4%.


And so with regard to the "mixed results", the critical question is: Mixed results in what sense?

Lots of hypops scored under the Alternative Standard? So the non-medicare RDI/AHI is well over 15, but the medicare approved AHI < 5, like me? Definitely "mixed results", but most docs who use the Alternative stanadard for scoring hypops are going to push a CPAP trial---particularly if the patient presents with any symptoms of OSA.

Too little sleep to officially qualify for a Medicare diagnosis? Just how bad/good were the numbers in the sleep that was recorded? And again, what symptoms does the patient present with?

Overall AHI/RDI borderline (possibly because of not getting much sleep), but a really high AHI in a very short REM period?

Overall AHI/RDI borderline and NO REM sleep recorded (possibly because of not getting much sleep), so there's no way to determine if the AHI would be higher in REM and enough to warrant a diagnosis?

And so the question may come down to: The tests results are mixed, but is it really worth the $$$ and time to redo the diagnositc sleep study in light of what kinds of symptoms Randy has and exactly why/how the test fails to meet the medicare standard for diagnosing OSA, but does still meet the pulmonology group's criteria for diagnosing OSA? It may be deemed prudent on the docs part and on Randy's part to simply go ahead and do the titration study and see if a CPAP actually does him some good.