Sleep Technology

In late 2020, free-standing and hospital-based sleep centers began receiving communications from Medicare Administrative Contractors (MACs) asking for attestations that they were in compliance with their local coverage determinations (LCDs) for polysomnography. LCDs are decisions made by a MAC whether to cover a particular item or service in their jurisdiction (region). MACs are contracted by Medicare to develop LCDs and process Medicare claims. The MAC’s decision is based on whether the service or item is considered reasonable and necessary. The Centers for Medicare & Medicaid Services (CMS) awards geographical jurisdictions to MACS (private health care insurers). National coverage determinations (NCDs) supersede LCDs, but LCDs provide expansion on coverage policies for each jurisdiction. Coverage policies vary among LCDs related to coding, credentialing, diagnostic testing and treatment. This means that Medicare coverage can also vary depending on the geographical location. LCD contractors must follow a specified procedure to issue an LCD, including holding public meetings to discuss a draft LCD, distributing it to medical groups, posting it on their website and offering a 45-day period for public comments (posted on their websites prior to finalizing the LCD).

As we see some light at the end of the tunnel with the U.S. advancing the rollout of COVID-19 vaccines, we also are seeing many school districts having students return to in-person or hybrid learning. The debate around what time school should start has always been a point of discussion for sleep professionals, physicians and parents.

It’s hard to believe 2021 is already half over. We’re well past the one-year mark of the start of the COVID-19 pandemic, and while cases are down in the U.S. and more and more people are getting vaccinated, we will continue to deal with the ramifications of the virus for years to come.

This is part two in the "For the Newbie" series. View part one here. Entering the field of sleep medicine can be daunting and intense or it can be fun and fascinating. Most of the time it is all of those combined! With this in mind, I’ve started a new series called “For the Newbie,” aimed at providing tricks of the trade for a new technician, or “newbie.” The objective of this series is to help trainees adapt to the sleep field and to remind their trainers what it was like to go through the process from a mindset, practice and routine standpoint.

Sexsomnia, known by layman terms as “sleep sex,” was once reported by nearly eight percent of patients at a sleep disorders center, and was more prevalent in men versus women, according to American Academy of Sleep Medicine. The first known case of sexsomnia was reported in 1986, and worldwide, only 94 cases have been documented, according to a 2015 study. It is a disorder that is believed to be unreported. 

While working at the Madigan Army Medical Center in Washington state, Vincent Mysliwiec, MD, FAASM, and his colleagues started to notice a unique phenomenon. Soldiers coming into the sleep lab were experiencing disruptive nocturnal behaviors and nightmares following traumatic experiences associated with their deployment. These symptoms which occurred frequently at home, would at times occur in the sleep lab where the patients would have REM without atonia (RWA) during polysomnography. It was odd — unlike other instances of PTSD-induced nightmares he had seen — and it made Mysliwiec think there was something more there. “It was definitely something distinct,” Mysliwiec said. “Everyone always goes, ‘That’s just PTSD.’ Yes, those with PTSD very frequently have nightmares, but nowhere in the PTSD criteria do they have disruptive nocturnal behaviors or dream reenactment.” Mysliwiec and his colleagues called the phenomenon “Trauma Associated Sleep Disorder” and classified it as a potential parasomnia. Their first paper on it was published in October 2014 in the Journal of Clinical Sleep Medicine. Since then, there are a growing number of clinicians and researchers finding evidence in their own labs that young soldiers, as well as veterans, might be experiencing something more intense than symptoms commonly associated with PTSD. Moreover, they believe further study of this proposed parasomnia could be a major preventative measure for long-term PTSD complications. “If you can actually say to a solider, veteran — or anyone suffering from traumatic exposure — that we have an established diagnostic criteria for the severe sleep disturbances you are experiencing, then you can begin to evaluate treatments for this disorder and prevent long[1]term adverse outcomes. We could potentially treat them for this potential parasomnia and improve their sleep and that of their bed partner.” he said. “It’s an important question — and we need researchers to develop the criteria.”

Dear AAST,

As a sleep professional, it's important that you educate your patients on parasomnias, such as a sleep-related eating disorder (SRED), since sleep disorders like these could negatively impact a patient’s health through weight gain and obesity. The journal Psychiatry provides these sleep-related eating disorder statistics:

In 1934, French researcher Henri Roger coined the term parasomnie (in English, parasomnia; from the Greek para meaning “alongside” and Latin somnum meaning “sleep”) for phenomena that occur in the transition from sleep to wake or vice versa. A parasomnia can occur during the transition between nonrapid eye movement (NREM) sleep and wake (i.e., NREM parasomnias such as sleepwalking, sleep terrors, confusional arousal, sleep-related eating disorder) or during the transition between rapid eye movement (REM) sleep and wake (i.e., REM parasomnias such as REM sleep behavior disorder [RBD], recurrent isolated sleep paralysis, nightmare disorder). A parasomnia has the following features: recurrent episodes of incomplete awakening from sleep, an inappropriate or lack of response to intervention or redirection during an episode, limited or no cognition of dream imagery and partial or complete amnesia for the event. In addition, the nocturnal disturbance is not explained by another sleep, psychiatric or medical disorder or medication/substance use. Some people experience REM parasomnias and NREM parasomnias, a condition called parasomnia overlap disorder (POD). A person with POD has a disorder of arousal (e.g., sleepwalking confusional arousal, sleep terror) and rapid eye movement sleep behavior disorder (RBD; which involves vivid, often unpleasant dreams; vocalization during sleep and sudden, often violent, arm and leg movements during REM sleep [i.e., dream-enacting behavior]).

Entering the field of sleep medicine can be daunting and intense or it can be fun and fascinating. Most of the time it is all of those combined! With this in mind, I want to provide some “tricks of the trade,” so to speak, for a new technician, or “newbie,” in a new series called “For the Newbie.” The objective of this series is to help trainees adapt to the sleep field and to remind their trainers what it was like to go through the process. A technician’s mindset, practice and routine are all important factors that will be beneficial as they enter the field of sleep.