The use of type III HST in dental sleep medicine has caused quite a bit of controversy. Some people in the medical community have voiced concerns about dentists being ill trained to use the HST equipment for diagnostic or even titration purposes.
There are companies selling type III HST equipment teaching dentists to screen their patients for sleep with the use of the HST. The dentist would then send the test data to a third party Board certified sleep physician to read, score, diagnose, and refer back to the dentist for treatment with oral appliances.
This practice of a dentist being involved in the diagnosis and using his/her equipment is the heart of major debates in dental sleep medicine. For the sleep physicians it is something they feel dentists should not be allowed. In several states the medical boards have worked with the dental boards to disallow it. Many of the medical insurances will not approve a dentist ordering a sleep test or using their equipment for diagnostic purposes. Medicare will not allow a dentist to be involved with the diagnostics or even to loan out the HST as this violates the Stark laws and can result in jail or large fines.
Using the HST for the purpose of checking the titration with the auto score features is an accepted practice. This is not a diagnosis and it is not an official scoring and interpretation. This is a guide to see objectively if the oral appliance is working and if not how best to treat. The use of the HST will allow the dentist to see body positions and snoring and apneic events. The dentist can then recommend adjunct therapies to help with treatment such as body positioning.
It is acceptable for a dentist to order a reading and interpretation from a board certified sleep physician with the titration HST for the purpose of board certification requirements documentation. It is however best to send the patient back to the diagnosing sleep physician to re-evaluate the treatment at 6 months post treatment.
For HST equipment used in titration studies I personally recommend equipment that can detect central and mixed sleep apnea. For most testers this requires the use of a RIP belt. I also want the tester to be under $10 per use in disposable supplies. We need to keep costs to a minimum because we may have to test several times. The equipment needs to be durable, and easy for the patient to use, and the cost to purchase or lease should be reasonable.
My favorite tester is the Alice Night One by Philips. It is about $1800 to purchase and cost about $6 per use. The Apnea Link Air by Resmed is another good one at a price about $2400, and the Medibyte Jr at about $3000 as well.
A question that is always asked of me when I lecture is, “can I put or loan out my HST equipment to medical doctors to use and in turn they send me the mild to moderate sleep apnea patients?” The answer is “probably not”. If the medical doctor accepts Medicare and you do this it is a violation of the Stark law for the medical doctor. If you are treating a Medicare patient even though you are not a Medicare provider then that is still a Stark law violation. If you are a Medicare provider and do this you have made a serious stark law violation. You cannot have any gifting or incentive to receive a patient. It is a non-influence policy with Medicare. For cash patients there are no specific laws I am aware of, but it is in bad taste and will offend other medical doctors and bring you unwanted negative attention.
Another question is, “Can I do dental sleep medicine without the HST for titration?” Yes you can, but not as well. You will never know the objective results unless the patient is tested and you would rely on the sleep physician to verify your treatment. Also you would not have all the tools to know if positional therapy is needed.
There are companies selling type III HST equipment teaching dentists to screen their patients for sleep with the use of the HST. The dentist would then send the test data to a third party Board certified sleep physician to read, score, diagnose, and refer back to the dentist for treatment with oral appliances.
This practice of a dentist being involved in the diagnosis and using his/her equipment is the heart of major debates in dental sleep medicine. For the sleep physicians it is something they feel dentists should not be allowed. In several states the medical boards have worked with the dental boards to disallow it. Many of the medical insurances will not approve a dentist ordering a sleep test or using their equipment for diagnostic purposes. Medicare will not allow a dentist to be involved with the diagnostics or even to loan out the HST as this violates the Stark laws and can result in jail or large fines.
Using the HST for the purpose of checking the titration with the auto score features is an accepted practice. This is not a diagnosis and it is not an official scoring and interpretation. This is a guide to see objectively if the oral appliance is working and if not how best to treat. The use of the HST will allow the dentist to see body positions and snoring and apneic events. The dentist can then recommend adjunct therapies to help with treatment such as body positioning.
It is acceptable for a dentist to order a reading and interpretation from a board certified sleep physician with the titration HST for the purpose of board certification requirements documentation. It is however best to send the patient back to the diagnosing sleep physician to re-evaluate the treatment at 6 months post treatment.
For HST equipment used in titration studies I personally recommend equipment that can detect central and mixed sleep apnea. For most testers this requires the use of a RIP belt. I also want the tester to be under $10 per use in disposable supplies. We need to keep costs to a minimum because we may have to test several times. The equipment needs to be durable, and easy for the patient to use, and the cost to purchase or lease should be reasonable.
My favorite tester is the Alice Night One by Philips. It is about $1800 to purchase and cost about $6 per use. The Apnea Link Air by Resmed is another good one at a price about $2400, and the Medibyte Jr at about $3000 as well.
A question that is always asked of me when I lecture is, “can I put or loan out my HST equipment to medical doctors to use and in turn they send me the mild to moderate sleep apnea patients?” The answer is “probably not”. If the medical doctor accepts Medicare and you do this it is a violation of the Stark law for the medical doctor. If you are treating a Medicare patient even though you are not a Medicare provider then that is still a Stark law violation. If you are a Medicare provider and do this you have made a serious stark law violation. You cannot have any gifting or incentive to receive a patient. It is a non-influence policy with Medicare. For cash patients there are no specific laws I am aware of, but it is in bad taste and will offend other medical doctors and bring you unwanted negative attention.
Another question is, “Can I do dental sleep medicine without the HST for titration?” Yes you can, but not as well. You will never know the objective results unless the patient is tested and you would rely on the sleep physician to verify your treatment. Also you would not have all the tools to know if positional therapy is needed.
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