Prior Authorizations for the Sleep Lab: Two Vignettes

Recently, I was discussing a prior authorization for a sleep study in the lab with a peer-to-peer medical director at a large insurance carrier. I will leave out all the names, but I do want to note that this physician unlike most we deal with on insurance issues is board certified in sleep medicine. I cannot begin to tell you how refreshing it was to discuss a case with someone who understands the intricacies of sleep medicine and the nuances of caring for complex patients. On the other hand, I cannot begin to tell you how (but will try) disappointed I was to hear this doctor register so many complaints about other physicians who seek to order sleep studies in the lab environment yet often present incomplete records and explanations for such requests.

To be fair, I never learned whether the discussion was strictly about other board-certified sleep physicians, so conceivably some of the complaints registered may have been directed at individuals working in the sleep field but who were not fully experienced or certified in the specialty of sleep medicine. I made the assumption we might have been chatting about an array of doctors, but I surmised that some of the individuals were boarded in sleep medicine, and once you hear the complaints I believe you will understand my presumption.

The conversation began with a brief discussion of the complex background regarding the patient for whom I was seeking a retitration study in the sleep lab. Due to common miscommunications that occur between sleep centers and the administrative staffs controlling prior authorizations, the paperwork with the essential history and objective test results from this patient never made it into the hands of the doctor with whom I was conversing. Once I was able to provide the appropriate updates and past history, the patient’s prior auth was approved. And, in this particular case, we discussed why a re-titration was necessary for someone who continued to suffer from poor outcomes and problematic mask fit issues, including leak and mouth breathing.

In these situations, I attempt to educate physicians who work for insurance carriers, because they may not understand certain technicalities associated with the superior value of in-lab PAP therapy titrations. In this case, the physician already knew about these nuances, so I was able to expand the conversation into our policies and procedures centered around the role of repetitive, rescue, retitrations (what we call REPAP) as I have previously described along with our general approach toward re-titrations.

The sleep doctor on the other end of the phone line was not surprised by any of this information and found it informative and interesting, but this individual commented on how unusual it was to receive all the essential information from a prescribing physician when discussing prior authorizations. I was confused and asked for elaboration.

We started in with a discussion of mask leak and how it is measured on the objective data download. The doctor stated that over 90% of physicians did not seem to know how to read or interpret leak values on a data download; and, these docs seemed unsure about their clinical relevance. Next up was the concept of residual events, which requires looking at both the AHI values provided on the data download as well as scrolling through the data to look at flow limitation graphs. Again, this medical director mentioned that many doctors do not pay attention to this information, do not know how to interpret it, and may not understand why it is clinically relevant in ordering a re-titration study.

I was greatly surprised by the proportion of physicians being described in this manner. It sounded as if not only the average doctor was having these problems, but arguably the vast majority of sleep-relevant physicians were not addressing these basic elements on the data download when making efforts to request an in-lab re-titration study. While this conversation occurred with only one physician working at only one insurance carrier, it certainly raises questions about how sleep doctors are practicing clinical sleep medicine and how they are engaging with insurance carriers to promote higher quality of care for their patients.

In another recent prior authorization phone call with another doctor at a different insurance carrier, the physician was not a sleep medicine expert. In this situation, we attempted to discuss their narrow criteria for letting someone forego home testing and instead complete an in-lab diagnostic study. I presented the following case to the physician: a young woman with severe obesity suffered from extremely severe insomnia taking several hours to fall asleep and often awake for several hours in the middle of the night. She has a history of a head injury and currently smokes. And, worse, she suffers from severe PTSD, bipolar disorder and depression, not to mention a past history of drug and alcohol dependence, including opiate addiction.

None of these issues qualified the patient for an in-lab sleep test even though she also reported sleep breathing complaints. In other words, having horrible insomnia that no doubt would dramatically confound findings, having a history of head injury, opiate addiction, and smoking all of which could create risks for central apneas, and finally having severe mental illnesses that might interfere with the patient’s ability to even correctly attach the wires of the device—all of these things were not sufficient to consider abandoning the idea of home testing. Only when the discussion turned to the possible cognitive impairment in this patient in so far as her potential difficulties in manipulating the home testing device was there finally some leeway, and the patient was permitted to undergo overnight sleep testing in the lab. Note the cognitive impairment was not assumed by having all these mental health problems, despite the definition of most mental health problems including some degree of cognitive impairment.

I’m all for home sleep testing in classic or straightforward sleep apnea, but as I have described previously, in our view these classic cases are much less common than the insurance carriers would like us to believe. In our population of patients at Maimonides Sleep Arts & Sciences, 70% or greater suffer mental health complications that exacerbate and co-occur with their sleep disorders. As others have described, it is often a waste of time, effort and money pushing patients into home testing when they cannot complete them. It does not save healthcare dollars and may steer patients away from more expedited care through the sleep lab. An important pearl in medicine often goes unheeded by professionals who staff the administrative side of healthcare: once patients fail in their first encounters in a healthcare system of any sort, it is not unusual for a long interval of delay to ensue prior to their return to the healthcare system for the very same problem.

Summing up, these were just two encounters, but from the grapevine I hear that many sleep physicians report obstacles to overcome in attempting to procure in-lab sleep testing. On the other side of the equation, it also sounds like some sleep professionals are not doing their homework in preparing the right information to accurately explain why their patients need in-lab sleep testing. Regardless of what the true state of affairs are in such circumstances, perhaps these vignettes will help patients encourage their sleep physicians to use all their resources to obtain in-lab sleep testing when appropriate.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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