Tips for Easing Prior Authorization for Sleep Studies

Obstructive sleep apnea (OSA) is a growing concern in the U.S. In 1990, the incidence of OSA in adults 30–70 years old was 11%.¹ By 2014, it had risen to 26%² and is now estimated at more than 30%.³ Sleep studies are key to identifying the condition, but getting insurance approval can be a barrier.

It's incredibly frustrating to assess your patient, determine the need for testing, and then have your patient's insurance company deem the service not necessary based on a technicality or miscommunication. It causes delays in care, as well as the extra administrative burden of going through an appeals process. But these denials can often be avoided. As two physicians who have experience working within the prior authorization process, we will attempt in this article to highlight the most common reasons for denials and provide best practices to make the process go more smoothly.

When you suspect OSA, perform and document a thorough sleep history and physical examination. Reviewers will assess your note to determine the patient's body mass index (BMI), neck circumference, cardiopulmonary function, and comorbid conditions. They will also look for documentation regarding the patient's level of daytime sleepiness. Without this piece of information, the prior authorization request will be denied, because that's ultimately the reason for doing a sleep study.

If the patient reports dozing off during the day even when trying to stay awake, best practice is to assess them using the Epworth Sleepiness Scale (see Table 1).⁴ A score of more than 10 suggests excessive daytime sleepiness that warrants further investigation. For these patients, the concern is that sleepiness is affecting their ability to function at work, at school, or while driving. But even for patients with an Epworth score above 10, prior authorization for a sleep study often requires documentation of at least two OSA risk factors. The most common risk factors that justify this test include habitual loud snoring, witnessed apneas or gasping and choking, diagnosed hypertension, BMI of 30 or more, or large neck circumference (17 or more inches in men and 16 or more inches in women). If patients score 10 or less on the Epworth scale, but they have serious comorbid conditions that may elevate the risks of sleep apnea, such as hypertension, diabetes, stroke, BMI of 35 or more, atrial fibrillation, or heart disease, they may still be good candidates for a sleep study.