GLP-1 Insurance Barriers Are Reshaping OSA Diagnostic Referral Patterns

Insurance-driven referrals for home sleep testing (HST) to meet GLP-1 therapy coverage requirements represented 15.3% of all HSTs performed in January 2026 at one center and accounted for 44% of all primary care referrals for sleep studies during the same period, according to a retrospective analysis presented at SLEEP 2026.¹

Tirzepatide (Zepbound) received US Food and Drug Administration approval in 2024 for moderate-to-severe OSA in adults with obesity, establishing the first GLP-1 receptor agonist and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist indication in sleep medicine. Coverage pathways have since become inconsistent across payers and states, with many insurers requiring documented OSA diagnosis before approving the medication, creating a new category of diagnostic referral driven by reimbursement requirements rather than clinical suspicion alone.

Andrew Ho, MD, the study's lead author, noted the pattern was consistent with what his team had been observing anecdotally.

"We were noticing more and more challenges to get tirzepatide covered," Ho said. "We did notice more referrals from the primary care field for sleep studies."

The analysis was prompted in part by changes to Medicaid coverage of tirzepatide for weight management in Pennsylvania beginning in January 2026, which appeared to accelerate referral volume.

HST Referral Characteristics, Symptom Documentation, and Diagnostic Yield in GLP Patients

All 111 HSTs performed in January 2026 were reviewed, with charts evaluated to determine whether each study was ordered for GLP-related coverage or standard clinical indication.¹ The 17 GLP-related referrals originated from weight management (47.1%), internal medicine (41.2%), family medicine (5.9%), and sleep medicine (5.9%). GLP patients trended younger than non-GLP patients (mean age 41.1 vs 48.4 years) and had higher mean BMI (40.4 vs 35.6 kg/m²), though neither difference reached statistical significance.

Comorbidity burden in GLP patients was substantial, with hypertension present in 52.9%, hyperlipidemia in 47.1%, asthma in 47.1%, GERD in 41.2%, prediabetes in 35.3%, and CKD in 5.9%.¹

Of note, pretest symptom documentation was limited across GLP referrals. The STOP-Bang questionnaire was absent in 65% of cases, snoring documentation missing in 58.8%, excessive daytime sleepiness in 58.8%, witnessed apneas in 82.4%, Epworth Sleepiness Scale in 94.1%, morning headaches in 94.1%, and poor sleep documentation in 88.2%.

Diagnostic yield among GLP patients showed 23.5% of studies were negative, 41.2% mild, 11.8% moderate, 11.8% severe, and 11.8% suboptimal, with a mean AHI of 17.0 events per hour (SD, 22.2) and ODI of 23.8 (SD, 25.4).¹ Nocturnal hypoxemia was present in 23.5%. Among non-GLP patients, mean AHI was 20.4 events per hour (SD, 20.0), with 25.5% demonstrating severe disease compared with 11.8% in the GLP group.

Clinical Implications for PCP Documentation and GLP-1 OSA Screening Strategy

The gap between referral volume and diagnostic yield raises practical questions about how primary care physicians should approach sleep study ordering in the context of GLP-1 coverage requirements. Ho noted the answer depends on what the referral is intended to accomplish. For patients with high clinical suspicion for OSA, standard screening protocols remain appropriate. For patients referred primarily to satisfy insurance documentation, symptom burden becomes the decisive variable once results are in hand.

"If it's for weight management and we don't have a test showing moderate to severe sleep apnea, and you're left with a patient with mild sleep apnea, the big question is symptoms, because that is what leads us to decide whether or not to treat them," Ho said.

He identified excessive daytime fatigue, poor sleep quality, snoring, and bed partner reports of disturbance as the symptom domains most useful for guiding treatment decisions in patients with mild disease who do not meet the threshold for tirzepatide coverage. Capturing this information before referral could shift diagnostic yield toward moderate-to-severe cases and improve the clinical utility of each study ordered.

An added complexity is insurance variability in accepted GLP-1 agents. Even when patients receive a confirmed moderate-to-severe OSA diagnosis, some payers are directing prescribers toward semaglutide, which does not carry FDA approval for an OSA indication.¹ Ho acknowledged the landscape remains unsettled and emphasized the need for longitudinal data to track how referral patterns and diagnostic yield evolve as coverage policies shift.²

References

1. Ho A, Sompalli S, Shariff T, et al. Home sleep testing for GLP coverage: utilization and diagnostic yield. Presented at: SLEEP 2026; June 2026.

2. Malhotra A, Grunstein RR, Fietze I, et al. Tirzepatide for the treatment of obstructive sleep apnea and obesity. N Engl J Med. 2024;391(13):1193-1205. doi:10.1056/NEJMoa2404881