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Insomnia Diagnostic Criteria for Payers

Gary L. Johnson, MD, MS, MBA, discusses the diagnostic criteria used by payers to differentiate between insomnia subtypes.


Peter L. Salgo, MD: Tell me about the diagnostic criteria that you as a payer look for to make this all rational.

Gary L. Johnson, MD, MS, MBA: We don’t actually require any diagnostic criteria for insomnia. It’s physician attestation. If the physician says the patient has insomnia, that’s all it takes.

Peter L. Salgo, MD: Wait. Here’s an insurance company just once saying we believe you? Doctors, you just certify and off we go? Do you come from Mars?

Gary L. Johnson, MD, MS, MBA: No, that’s the truth.

Peter L. Salgo, MD: Or is it simply because there’s not enough data?

Gary L. Johnson, MD, MS, MBA: Now, if you’re asking about a sleep study, that’s a different animal.

Peter L. Salgo, MD: Would you pay for a sleep study based on their attestation?

Gary L. Johnson, MD, MS, MBA: They’re prior authorized, so there are some criteria to pay for a sleep study.

Peter L. Salgo, MD: What would that be?

Gary L. Johnson, MD, MS, MBA: I would have to look up the medical policy. I don’t know what it is.

Peter L. Salgo, MD: It probably varies from company to company.

Gary L. Johnson, MD, MS, MBA: Oh, of course it does. I think it would be the generally accepted criteria to have a sleep study. But just for the diagnosis of insomnia, it’s physician attestation that’s done mostly by primary care physicians.

Sanford H. Auerbach, MD: Yes. As far as sleep studies go, they’re generally done if there’s a suspicion of sleep apnea. They’re generally done if people have these various excessive sleepiness problems like narcolepsy-related problems, but generally not for insomniacs.

Gary L. Johnson, MD, MS, MBA: I have a feeling that we’re kind of comingling sleep apnea and insomnia. I guess I think of those as 2 separate disorders. Not everybody with sleep apnea has insomnia, and by no means, everybody with insomnia doesn’t have sleep apnea. They’re 2 different diagnoses.

Peter L. Salgo, MD: Are there ICD-10 [International Classification of Diseases, 10th Revision] codes? And are there different ones for chronic versus primary versus secondary?

Karl Doghramji, MD: Well, there may be, and I think chronic is defined as a few months or longer, acute being less than that; primary, secondary. But as I said before, clinically, those distinctions between primary and secondary aren’t all that useful, unfortunately. And even the chronic and acute distinction, clinically, is not that useful because both can be very consequential.

Sanford H. Auerbach, MD: The International Classification of Sleep Disorders, the ICSD-3 [third edition], actually did away with those distinctions. It’s insomnia or not.

Karl Doghramji, MD: We’re now calling it a disorder. It’s a disorder in and of itself, insomnia disorder.

Peter L. Salgo, MD: Are there some neurologic conditions that of and by themselves present greater risks of insomnia?

Sanford H. Auerbach, MD: Well, certainly besides the sort of obvious things people have, back problems and pain, I think one of the things you’re hinting at is certain neurodegenerative disorders where sleep problems are very common and very prominent. Parkinson disease or disorders similar to Parkinson’s disease may have sleep problems very early in the course. And a lot of emphasis is placed on these nonmotor symptoms of Parkinson’s disease and related sorts like dementia with Lewy bodies and so forth. Patients with Alzheimer disease may also develop, in the course of the disease, sleep problems. In fact, many times, the leading reason why families can’t take care of patients at home anymore is because they don’t sleep at night, and the families can’t tolerate staying up all night. So yes, it can oftentimes be the leading part. In fact, in my particular practice, I work with sleep patients, and I also see lots of patients with these memory disorders and other neurodegenerative disorders. And the 2 populations sort of mix from time to time.

 
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