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Title of Proposal:

Reforming health insurance processes for patients obtaining sleep medicine procedures and therapies

On behalf of:       

Virginia Academy of Sleep Medicine

Describe the Idea or Issue:

The need to reform health insurance processes to eliminate prior authorizations and appeals for patients obtaining sleep medicine procedures and therapies. Insurance companies create barriers to obtain sleep related health care. These processes are interfering with patient care, prolonging hospitalizations, and affecting patient safety, thus increasing short term and long term health care costs.

Desired Outcome:

MSV support with communication and policy changes to improve timely delivery of health care by approving procedures and access to sleep medicine therapies.

Background/Supporting Information:

  1. Sleep Apnea
    • Prior Authorizations:
      • Several health insurance plans have improperly denied attended/in-lab sleep studies (CPT codes 95810, 95782) on pediatric and adult patients. Insurance companies are citing limited literature, not always based on evidence based medicine, and using selection criteria that is not well defined (such as COPD/severe lung disease, heart failure, stroke within 30 days, or inability to have testing at home) to support their denials. Insurance companies have inappropriately applied the AASM clinical practice guidelines for diagnostic testing and not only denied in-lab studies, but required HSAT (Home Sleep Apnea Tests) for a majority of patients without any justification.
      • Patients with hypoxemia that would also benefit from attended/in-lab titration studies (CPT Code 95811, 95783) are being denied. Previously the criteria for an in-lab positive airway pressure (PAP) titration study was performed if the patient had an oxygen saturation nadir <80%, however these studies are no longer approved. Insurances are requiring providers to order auto-PAP machines and perform home pulse oximetry, which is suboptimal and impacts patient care.
      • According to some insurance plans, pediatric patients are required to have a split- night sleep study since the insurance plan is denying a second study for the purpose of a PAP titration. The insurance companies are incorrectly extrapolating data from the adult studies to pediatric patients. Evidence has shown that PAP desensitization protocols prior to the titration study helps to improve compliance to PAP in the pediatric population (Harford et al, Clin Child Psychol Psychiatry 2012).
      • Managing requests and appeals with peer to peer reviews (usually conducted with a non-sleep physician) is burdensome and time-consuming. Some insurance companies have imposed restrictive and onerous time limitations when the peer to peer reviews can be completed and can close the case at the end of the day the same day the denial letter was sent.
      • On-line precertification which is required by some insurance plans, is returned with a “Pending Review” status. It usually takes 3 days from the time the request is submitted before a response is posted online. The delay is time consuming, particularly since these plans did not require precertification for a sleep study prior to 01/01/2017.
      • The delay in approval of authorizations affects timely treatment of comorbidities (such as arrhythmias, hypoxemia, stroke, fatalities linked to driving sleepy).
  • Insurance companies are prolonging hospitalizations by demanding unnecessary testing:
  • Criteria for discharging home with PAP may include:
    • Obtaining an arterial blood gas to document elevated CO2 levels. This can increase medical risk (due to infection, bleeding, morbidity due to pain when obtaining a blood gas) and produce inaccurate misleading results by waking the patient up and causing pain, thus increasing ventilation causing falsely normal CO2 values.
    • Performing a polysomnography as an inpatient. This may not be possible since they are not available in some hospitals, and incur more costs when they are obtained as an inpatient versus an outpatient study.
    • Obtaining a Forced vital capacity (a pulmonary function test) which may be difficult to perform as the patient may be unstable to leave the ICU and unable perform an accurate FVC maneuver; pediatric patients are often unable to perform this test even when well.
  • Increasing hospital length of stay due to trying to document sleep apnea and coordination of home supplies
  • Forcing discharge of patients home without positive airway pressure (PAP) therapy and waiting to perform an outpatient study, which increases their comorbidities
  • Decreased quality of life by prolonging time back to work or school since patients are not effectively treated for their underlying health concerns
  • Narcolepsy
  • Health insurance plans have denied medications for narcolepsy patients based on age or recommending to trial other medications with “step therapy” such as stimulants (which have side effects such as arrhythmias) or other treatment modalities prior to accessing more effective medications such as Modafinil.
    • Requires patients and physicians to delay optimal treatment which places patients at risk for sleep deprived accidents and fatalities
    • Medication denials create barriers for patients to receive medication that may be their best treatment option. This affects patients quality of life due to untreated excessive sleepiness leading to failing their classes, repeating the school year, and time off work
    • If the patient has been stable on a medication for years and changes insurance companies, then the patient needs to start the entire “step therapy” process again with less effective medications.

Additional background materials in appendix.

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Comments

I have had knock down / drag out fights with nursing "managers" who refuse to follow orders to institut CPAP on inpatients, because they know it's virtually impossible to get an in house sleep study or appropriately get CPAP prescribed/configured for inpatients prior to discharge.

 

These are at risk patients, acute postop surgical patients, who are going home with new diagnosis of sleep apnea, new Rx for multimodal pain therapy (including narcotics), and NO option to get them PAP therapy they need.

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