Physician Resources - Frequently Asked Questions and Answers
Which patients need sleep tests?
Which sleep test should I order?
Should patients take their usual medications before a sleep test?
How do my patients learn about their sleep testing result?
How do I make a referral to one of your sleep centers?
What is the typical wait time for patients to be scheduled for
a sleep study?
What insurances are accepted by your sleep centers?
Will Medicare pay for CPAP treatments?
What if a patient who needs a CPAP treatment does not qualify for insurance coverage?
How does the interpreting sleep doctor determine which CPAP pressure to recommend?
What if the CPAP Titration fails or the patient does not tolerate it well?
Will your sleep center order the CPAP machine for my patient?
How do I instruct my patients to get used to using a CPAP machine?
What if my patient still cannot use the CPAP machine?
How does the dental appliance work for Obstructive Sleep Apnea (OSA)? When should I prescribe it?
What is the difference between Restless Leg Syndrome (RLS) and Periodic Limb Movements of Sleep (PLMS)?
Which patients need sleep tests?
In general, patients with a high probability of having Sleep Apnea need a
Polysomnogram (PSG) to officially diagnose for Sleep Apnea and determine its
severity. Patients with severe sleepiness during daytime, who are otherwise
not chronically sleep deprived and have no other apparent causes for sleepiness,
also need testing. These patients need a PSG to determine whether they have
Sleep Apnea or Periodic Limb Movements of Sleep (PLMS). In addition, such
patients usually benefit from a Multiple Sleep Latency Test (MSLT) to determine
the degree of sleepiness during daytime and to whether they have sleep-onset
REM periods (as do most Narcolepsy patients). Patients with Insomnia usually
need a diagnostic testing only if the Insomnia has persisted for more than
six (6) months despite having gone through other methods of treatment.
Which sleep test should I order?
A Polysomnography (PSG) alone is usually adequate to assess most patients
with suspected Sleep Apnea. The Multiple Sleep Latency Testing (MSLT) is used
selectively to further evaluate patients for daytime sleepiness and other
possible sleep disorders.
A Split-Night Sleep Study is especially beneficial if the patient has a previous
known diagnosis of Obstructive Sleep Apnea (OSA) (or high probability of having
OSA) and after the physician has already discussed various treatment options
with the patient and the patient already has a good idea of the treatment
nature and value of using a Continuous Positive Airway Pressure (CPAP) machine.
A Split-Night Sleep Study enable a physician to diagnose/confirm the presence
of OSA and determine the optimal treatment air pressure for a CPAP machine
in one (1) overnight test. During a Split-Night Sleep Study, the Sleep Technologist
is instructed to perform a standard, diagnostic PSG for at least two (2) hours
of sleep initially. The consensus statements of American Academy of Sleep
Medicine (AASM) recommend that CPAP Titration be initiated for patients with
the following PSG results:
• An Apnea/Hypopnea Index (AHI) of at least 40 per hour, documented
for a minimum of two (2) hours during the initial PSG phase of the Split-Night
Sleep Study
• An AHI of 20 to 40 if there is a presence of repetitive long obstructions,
major oxygen desaturations or other documented clinical reasons as to why
less than a full-night sleep study is warranted.
A Split-Night Sleep Study protocol may cut the cost of diagnosis and treatment
initiation for Sleep Apnea in half for many patients; however, but it requires
that the Sleep Technologist make the initial diagnosis based on an “incomplete”
recording. Since apneic episodes often are more frequent or more severe during
the REM stages of sleep (and since REM stages of sleep usually predominates
in the latter half of the night), a two (2)-hour initial baseline PSG may
significantly underestimate the baseline severity of Sleep Apnea. The effects
of body position on breathing may be missed during an abbreviated PSG study,
and there may not be sufficient time during the CPAP Titration phase of the
study to completely determine that the breathing has been corrected in all
body positions in all stages of sleep. Despite these limitations, a Split-Night
Sleep Study can be a valuable tool to reduce the cost and the number of sleep
tests performed; however, a major disadvantage is that many insurance companies
require a pre-approval/pre-authorization.
In addition, some patients may sleep poorly at a sleep center, and they may
not complete two (2) hours of sleep until three (3), four (4) or more hours
have elapsed. CPAP Titration will not be started for these patients since
there will not be enough time left to allow a complete and accurate determination
of the optimal CPAP treatment pressure.
Please note that some patients with mild case of OSA may still benefit from
CPAP treatment; however, we do not start CPAP Titration if the AHI (or RDI)
is below 20-40 per hour during the initial baseline period because these patients
may choose alternate treatment methods, such as dental appliance therapy,
and/or a half-night study may miss the most severe apneic episodes that can
occur later in the night.
Should patients take their usual medications
before a sleep test?
Many medications, such as antidepressants and benzodiazepines, may change
the natural sleep structure. In addition, a sleep test itself usually changes
the natural sleep structure. Antidepressants may worsen snoring, Sleep Apnea
and PLMS. Benzodiazepines may also worsen snoring and Sleep Apnea but may
improve PLMS. In general, most referring physicians wish to answer a clinical
question about a patient's sleep under his/her daily conditions, we usually
recommend that patients take all of their daily medications before the sleep
test.
Alcoholic beverages can worsen snoring and Sleep Apnea, and many patients
routinely consume alcoholic beverage every night. We do not allow our patients
to bring or consume alcoholic beverages to any of our sleep centers, and we
do not encourage, suggest or recommend them to consume them before driving
to our centers.
If a patient has a significant Insomnia at home but requires testing for possible
Sleep Apnea, we can suggest a prescription, short- to medium- duration hypnotic
medication. The patient can fill the prescription at a pharmacy, brings it
to the sleep center, and take it after arrival. In this case, the patient
may need a ride home in the morning due to the residual effect of the hypnotic
medication. The referring physician needs to consider the advantages and disadvantage
of using such hypnotic medications since there is a small possibility that
they can affect various sleep stages and respiration (vs. concerns that the
test may not result in a complete diagnosis if the patient does not sleep
for a long-enough of a time without the hypnotic medication).
How do my patients learn about their
sleep testing result?
Your patients learn the results of the sleep study as they would learn the
results of any other diagnostic procedures such as an X-ray, MRI or blood
work. We forward the study result directly to your office via fax and mail
within two (2) to three (3) business days, and we instruct them to contact
your office directly. In addition, we provide a copy to your patients directly
in person or via mail if they specifically request one in writing.
How do I make a referral to one of
your sleep centers?
To make a referral to GWSDC, please complete the Order Form (link to Order
Form) for your patient and fax it directly to the number specified on the
Order Form. To obtain an additional Order Forms, please call 1-800-AWAKEN-1
(800-292-5361).
What is the typical wait time for
patients to be scheduled for a sleep study?
Patients can be scheduled usually within one (1) to two (2) weeks. Unless
you or your patients make a request to be scheduled at a specific sleep center
location during a specific time period, they will be scheduled for the first
appointment time available.
What insurances are accepted by your
sleep centers?
We accept Medicare and most other indemnity and managed care insurance payments,
and those plans usually pay between 80 to 100 percent of the test costs. Please
call us directly at 1-800-AWAKEN-1 (1-800-292-5361) to verify that we accept
or participate in your patient's plan.
Will Medicare pay for CPAP treatments?
Under the new 2002 policy, CMS approves CPAP treatment payments for patients
with an Apnea/Hypopnea Index (AHI) 15 or more and for patients with an AHI
of 5-14 with documented symptoms of excessive daytime sleepiness, impaired
cognition, mood disorders or Insomnia. In addition, documented cases of hypertension,
ischemic heart disease or history of stroke are also paid. The AHI must be
based on a minimum of two (2) hours of sleep recorded by Polysomnography (PSG)
using actual recorded hours of sleep (e.g., the AHI may not be extrapolated
or projected). Apnea is defined as a cessation of airflow for at least ten
(10) seconds. Hypopnea is defined as an abnormal respiratory event lasting
at least ten (10) seconds with at least a 30% reduction in thoracoabdominal
movement or airflow as compared to baseline and with at least a 4% oxygen
desaturation. PSG must be performed in a facility-based sleep study laboratory
and not in a home or mobile facility.
The specific policy wording is important. For patients to have coverage for
a CPAP treatment, their diagnostic tests must be a PSG with sleep staging,
not sleep studies that measure only cardiopulmonary data, and Split-Night
Sleep Studies must include a baseline of 120 minutes of recording. Most sleep
centers have adopted the Medicare hypopnea definition for all patients since
it is almost impossible to use separate scoring rules only for Medicare patients.
To reduce difficulty for patients, DME providers, and prescribing physicians,
our test result reports clearly state the AHI and a summary of patient symptoms.
What if a patient who needs a CPAP
treatment does not qualify for insurance coverage?
There are some patients who would benefit from a CPAP treatment for sleep-disordered
breathing but do not meet the Medicare or private insurer coverage criteria.
For example, some patients have very frequent arousals because of increased
breathing effort but do not have oxygen desaturations. These patients will
have a high respiratory disturbance index (RDI), but they may have a low number
of apneas and hypopneas. Their Apnea/Hypopnea Index (AHI) will be low. Patients
with Upper Respiratory Resistance Syndrome (URRS), a type of sleep-disordered
breathing, have a low AHI and also may have a low RDI. On a CPAP treatment,
these patients may have a significant improvement in sleep continuity and
in alertness, but they may not qualify for the CPAP treatment coverage by
Medicare criteria.
We cannot alter the medical data to meet the coverage requirement. Medicare
patients who are in this type of a situation may write to their Congressional
Representative(s). We advise privately insured patients to apply for coverage
waivers.
How does the interpreting sleep
doctor determine which CPAP pressure to recommend?
When our Sleep Technologists initiate a CPAP Titration, they raise the pressure
to eliminate apneas, hypopneas, desaturations, and snoring. The lowest pressure
that eliminates all of these events is the pressure we recommend for the CPAP
machine usage at home. At too low of a pressure, snoring or sleep-disordered
breathing may persist. At too high of a pressure, patients may not tolerate
the CPAP treatment as well, and Central Respiratory Apneas may appear. Because
tested pressures range from a low of about 4 cm H2O to a high of about 20
cm H2O, with many steps in between, the patient may sleep only for a short
time at each of these pressure levels. The interpreting physician then may
recommend a pressure that was effective at relieving the Obstructive Sleep
Apnea (OSA) when the patient was sleeping supine, during the REM stage, when
sleep disordered breathing is expected to be the worst for many patients.
Depending on other clinical factors during the treatment, the treating physician
may choose to adjust the CPAP pressure higher or lower than the originally
recommended pressure.
Commercial, FDA-approved devices deliver CPAP pressures reliably as prescribed.
The choice among machines is dictated by size/appearance, associated features
such as heated humidifiers, and the brands carried by the DME provider who
contracts with the patient's insurance company.
What if the CPAP Titration fails
or the patient does not tolerate it well?
In one study, full-night CPAP titration failed in 16% of cases to find an
effective treatment pressure, and the failure rate is higher for Split-Night
PSGs. Without enough data to determine the likely effective pressure, the
interpreting physician may recommend a repeat test. For example, if a patient
did not sleep much with a CPAP machine, a repeat test may be helpful after
the patient has taken a prescription hypnotic medication.
Several studies have demonstrated that many patients can benefit from using
a CPAP machine even if the CPAP Titration study was not perfect. In such cases,
the interpreting physician may recommend a starting pressure and recommend
a repeat CPAP Titration test after the patient has become accustomed to using
a CPAP machine.
Will your sleep center order the
CPAP machine for my patient?
CPAP treatment requires a physician’s prescription. Our sleep center
physicians prescribe a CPAP treatment only for patients they have actually
evaluated and had a consultation with. When our physicians only interpreted
a patient’s test result but did not actually have a consultation to
evaluate the patient, they do not directly prescribe any treatments, including
medication, surgery, dental appliance or CPAP therapy.
How do I instruct my patients to
get used to using a CPAP machine?
The long-term compliance with a CPAP machine can be improved with good patient
education and guidance. After using a CPAP machine at a sleep center, about
70%-80% of patients accept a home trial. Patients who will likely use the
CPAP machine usually develop a compliance pattern within the first four (4)
days of trial at home, and out of those, 90% will likely continue to use after
three (3) years (and 85% after seven [7] years}. Patients who will give-up
using it will usually do so within the first few months. Our physicians almost
always recommend or prescribe a twenty (20)-minute “ramp” to full
pressure, a baffle humidifier, a second CPAP mask, and the following gradual
CPAP desensitization program (a method developed after Edinger and Radtke)
for all patients:
Step 1. Wear the CPAP mask (or nasal pillows) at home while
awake in the evening and performing normal evening activities for about one
(1) hour daily. When one can do this without anxiety or concern for several
days, or up to five (5) consecutive days, then go to Step 2.
Step 2. Connect the pressure device and the tubing and set
the machine at the pressure prescribed by your doctor. Turn on the machine
and breathe through it at rest at home for one (1) hour daily. When one can
do this without anxiety or concern for up to five (5) consecutive days, then
go to Step 3.
When one is getting used to using the CPAP machine in Step 1 and Step 2, he/she
can practice putting on the mask with eyes closed, experience how the pressure
ramps up, and practice moving the head at the full pressure to get used to
the mask leak (and how to stop the leak). The bed partner and other family
members should get used to seeing and touching the CPAP machine so they are
not afraid of it! Please remember that CPAP is just pressurized air, not oxygen,
so it is not dangerous or flammable, and it will not blow up!
Step 3. Wear the entire CPAP apparatus for a scheduled one
(1)-hour nap. When one can do this without anxiety or concern for five (5)
consecutive days, then go to Step 4.
Step 4. Wear the entire CPAP apparatus for 4-5 hours of sleep
each night. When one can do this without anxiety or concern for five (5) consecutive
days, then go to Step 5.
Step 5. Use the CPAP machine for the entire night's sleep.
When patients experience no difficulty using CPAP machine at a sleep center,
we recommend beginning at Step 2 and then progressing quickly to Step 5. Please
call us for a copy of general recommendations to patients about CPAP machine
use and traveling.
What if my patient still cannot
use the CPAP machine?
About 50% of patients, who fail CPAP initially, will still be able to use
a CPAP machine. We recommend these steps:
• Review the CPAP Titration test result to determine whether lower pressures
were effective during the test
• Consider switching from CPAP to Bi-Level PAP (or BiPAP), and when
starting a BiPAP treatment without a separate titration, we usually recommend
setting the BiPAP Inspiratory Pressure at the prescribed CPAP pressure and
the Expiratory Pressure at about 4-6 cm H2O lower
• Be sure the patient is using a humidifier, and consider using a heated
humidifier, which is more effective for a small number of patients
• Switch to a different mask size or style
• Consider a trial of a prescription hypnotic medication to be taken
before the PAP machine is started
• Consider measures to improve nasal potency such as using a nasal steroid
spray or an oral decongestant medication
• Restart the desensitization program as outlined above.
How does the dental appliance work
for Obstructive Sleep Apnea (OSA)? When should I prescribe it?
Airway dilators (also referred to as dental devices or oral appliances), originally
developed to correct occlusal disorders, have been approved by the FDA to
treat sleep-disordered breathing. These devices are inserted intraorally at
night to anteriorly displace the mandible and tongue, enlarging the retroglossal
space and reducing upper airway obstruction. The airway dilator can be constructed
in a laboratory from impressions prepared in a dental office. Airway dilator
treatment is generally well tolerated, safe, reversible, and cost effective.
A task force of the American Academy of Sleep Medicine (AASM) has recommended
that oral appliances are indicated for patients with primary snoring or mild
OSA who do not respond to behavioral treatments or who are not appropriate
candidates for behavioral treatments. The task force also recommended that
oral appliances are indicated for patients with moderate to severe OSA who
fail or refuse CPAP or surgical treatments (An American Sleep Disorders Association
Report. Practice Parameters for the Treatment of Snoring and Obstructive Sleep
Apnea with Oral Appliances. Sleep 18: 511-513, 1996). An AASM task force reviewied
this practice parameter during 2003-2004. Airway dilators should be prescribed
cautiously in patients with Temporomandibular Joint (TMJ) Dysfunction, dental
complications such as bridges or implants, and bruxism.
A number of dentists fit and supply airway dilators in their offices, but
patients may have a difficulty in arranging insurance coverage for such dental
visits.
What is the difference between Restless Leg Syndrome (RLS)
and Periodic Limb Movements of Sleep (PLMS)?
RLS occurs in patients who are awake, and PLMS occurs in patients who are
asleep. Up to 10% of people in general can experience a restless feeling,
particularly in the legs, which usually becomes bothersome during the late
evening hours. Patients describe numbness, cramping or other symptoms, which
improve when they move their legs. These symptoms often interfere with the
sleep onset and often lead to long awakenings after the sleep onset. About
10% of people may have regular, repeated, uncontrollable leg twitches/jerks
as they sleep, and the resulting arousals disturb sleep. Most people with
RLS or PLMS have both disorders, and medical treatment usually is effective.