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Shift in Diagnosis, Treatment of Obstructive Sleep Apnea A Challenge for Otolaryngologists

by Amy Eckner •

Dr. Yaremchuk believes that minimally invasive robotic surgery will continue to improve outcomes for OSA treatment, allowing surgeons to reach anatomical areas that were problematic in terms of access. “There is preliminary data on its effectiveness, but we like to see large studies. Because OSA robotic surgery has been prevalent for only a few years, we just don’t have those kinds of studies yet.” She also trials of a hypoglossal nerve stimulator to bring the tongue forward—“similar to a pacemaker for the tongue. It’s in clinical trials now, but it does show promise.”

Again, insurance coverage can play a pivotal role in surgical treatment options. Dr. Wardrop said that although many providers will pay for palatal surgery, they may not cover base-of-tongue procedures. “The situation is complicated by the fact that there aren’t high-level studies,” she added. “It’s hard to get large numbers of patients who have had the same procedures, so surgical comparison studies don’t often compare apples to apples.”

Dr. Ishman is encouraged by data on who is performing sleep surgery, however. “In our study, we saw an increase in surgery by physicians who do only a low volume of cases per year,” she explained. “This may be a sign that, in general, more otolaryngologists feel more comfortable doing these procedures now.”

“We must determine how to maintain continuity of care with patients to ensure they receive the services they need—keeping track of people, especially if they’ve received testing outside of your office,” said Dr. Yaremchuk. “Make sure you let patients know they need to follow up, and give them options when a particular therapy—whether weight loss, an oral appliance, CPAP or surgery—isn’t working.”

CMS CPAP COVERAGE

In its National Coverage Determination for CPAP Therapy for OSA (NCD 240.4), created in March 2008, CMS made several determinations about covered OSA diagnosis and treatment:

A positive OSA diagnosis must include a clinical evaluation and:

  • A positive attended PSG performed in a sleep laboratory; or
  • A positive unattended home sleep test (HST) with a Type II home sleep monitoring device; or
  • A positive unattended HST with a Type III home sleep monitoring device; or
  • A positive unattended HST with a Type IV home sleep monitoring device that measures at least three channels.

CMS allows for an initial 12-week period of CPAP for adult patients if either of the following criterion using the apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) are met:

  • An AHI or RDI greater than or equal to 15 events per hour or
  • An AHI or RDI greater than or equal to five events 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.

(Per CMS, AHI or RDI is calculated on the average number of events per hour. If the AHI or RDI is calculated based on fewer than two hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing must be at minimum the number of events that would have been required in a two-hour period.)