Abstract Introduction Hypoglossal nerve stimulation (HGNS) requires an apnea–hypopnea index (AHI) ≥15 with 25% central events. Many payers, including Medicare, still mandate the outdated 4% oxygen-desaturation criterion, despite evidence that the 3% rule is more physiologic and better aligns with cardiovascular outcomes. Multi-night home sleep apnea testing (HSAT) improves diagnostic reliability, but the impact of scoring rule choice on HGNS eligibility in Medicare-eligible adults (age ≥65) has not been quantified. Methods Using a large multi-night HSAT dataset, we applied standardized inclusion criteria consistent with multi-night validation literature: • recording time ≥4 hours; • ≥1 hour of inferred sleep; • ≥2 valid nights included; • up to 7 consecutive nights analyzed. For each patient, nightly AHI was calculated using both 3% and 4% hypopnea rules. Medicare-eligible patients were defined as age ≥65. HGNS eligibility required AHI 15–65 on at least one night. “Rescued” patients were those eligible under the 3% rule but ineligible under the 4% rule. Results A total of 4, 255 multi-night HSAT patients met inclusion criteria, of whom 738 (17. 3%) were Medicare-eligible. Among these older adults: • HGNS-eligible using the 3% rule: patients with any-night AHI₃% ≥15 • HGNS-eligible using the 4% rule: patients with any-night AHI₄% ≥15 • Rescued by the 3% rule: 169 of 738 (22. 9%) who qualified under 3% but were excluded under 4%. Most rescued patients had worst-night AHIs between 15–20, a zone where small scoring shifts translate into major eligibility differences. Conclusion In this large multi-night HSAT cohort, nearly one in four Medicare-eligible adults who legitimately meet the HGNS AHI threshold under the physiologic 3% rule are excluded when the 4% rule is applied. This diagnostic misalignment disproportionately affects older adults, the population with the highest cardiometabolic risk and the greatest potential benefit from HGNS. These findings support updating payer scoring policies to adopt the 3% rule and reduce inequitable barriers to therapy access. Support (if any)
Jain et al. (Fri,) studied this question.