Debunking the RDI Insurance Myth
TLDR: The largest insurance companies in the US all accept RDI for an OSA diagnosis.
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Disclaimer: Some of you might already know this, which is great, but this was a shocking discovery to me given how often I hear the opposite. Hopefully this post can help some patients in need.
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The Myth: Insurance does not recognize RDI in the diagnosis and coverage of OSA.
I have read and heard this countless times on subs and forums, and directly from sleep docs.
Adverse Outcomes
This myth has negative health consequences. There are countless stories on this sub of patients going undiagnosed and/or untreated. These are largely a function of the insurance myth:
- Many sleep doctors still do not consider RDI in their diagnoses.
- Many sleep doctors still use outdated at-home technology that does not even calculate pRDI.
- Many sleep labs still do not score RERAs nor calculate RDI (or do not do so properly).
- Meaning, many would-be UARS patients go undiagnosed and untreated.
Debunking the Myth
- CMS (Medicare/Medicaid): This is the largest insurer in the US. Read the guidelines here.
- "OSA has often been defined by an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) of ≥ 5 events per hour during sleep"
- "Medicare covers CPAP for the treatment of OSA if the beneficiary has an AHI or RDI ≥ 15 events/hour"
- United Healthcare: This is the largest private (commercial) insurer in the US. Read the guidelines here.
- "OSA severity is defined as: Mild for AHI or RDI ≥ 5 and < 15 Moderate for AHI or RDI ≥ 15 and ≤ 30 Severe for AHI or RDI > 30/hour"
- Anthem/Elevate: Second largest private insurer. Read the guidelines here.
- "For the purposes of this guideline, the terms AHI, RDI, and REI may be used interchangeably."
If you read others like Aetna, they are all the same (though there may be some I didn't read that only count AHI).
Related Myths
- UARS is a Type of OSA: This is true from an insurance standpoint but not necessarily from a scientific/medical one. The adverse impact is that it is treated as a "lesser form" of OSA.
- UARS is a "Mild" Form of OSA: Debilitating symptoms such as EDS have been shown to be more severe in UARS patients than in "mild OSA" patients. The adverse impact is that doctors do not take UARS patients seriously, do not provide adequate care, and/or diagnose with idiopathic hypersomnia (or refer elsewhere) if the patient does not respond to minimal treatment.
- AHI > 30 is Required for Surgery Coverage: Surgery (especially MMA) is rightfully the last resort given it can be highly invasive. However, many doctors do not even go down that path out of fear that insurance will not cover it, and the cost is prohibitive to most paying out of pocket. Although there is no data on the approval rates, the insurance guidelines lead me to believe that many more patients can get surgery covered.
- United: MMA for OSA is covered if the patient has RDI > 15, ESS > 10, failed PAP, and has jaw deformities.
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Discussion
The state of sleep medicine is clearly in disarray. The AASM guidelines contradict themselves (source), sleep studies are not standardized, doctors are not familiar with the basics of UARS, and insurance coverage myths persist that negatively impact health outcomes, particularly because they are perpetuated by the doctors themselves. This is a travesty, as anyone who has spent time on this sub already knows. What does this mean in practice?
It means that us, the patients, must navigate diagnostic tooling, medical literature, treatment options, and insurance coverage on our own. It means that, often, the best we can hope for is to convince our doctor to (a) take us seriously, and (b) prescribe more advanced treatment options.
Thankfully, the next-gen at-home sleep tests can score pRDI, which they claim is ~90% correlated to an in-lab PSG, meaning it should be a "good enough" proxy for RDI and a UARS diagnosis. And thankfully, researchers and practitioners such as Dr. Barry Krakow and Dr. Avram Gold continue to research and/or advocate for proper diagnosis and treatment of UARS. What does this mean in practice?
- Ensure your sleep test will score RERAs and RDI (or pRDI) in advance of the test
- Share the latest research with your doctor if they don't take you seriously
- ...or find a doctor more expert in UARS
- Check your insurer's coverage guidelines and share them with your doctor
- Develop a treatment plan and do not stop until all symptoms have resolved
- Most importantly, be the CEO of your health.
I hope this is helpful to those seeking help with a diagnosis, treatment, or insurance coverage. I welcome all discussion.