Insurance rejects Dr's Sleep Study referral

[metsfan302]

well after getting home from work and a night sleep, I have read over the papers my insurance sent me. It says I can appeal it, "might take 45 days or if me or my doctor believe that waiting 45 days to decide your appeal could seriously risk your life or health, including your being able to reach, keep, or get back your maximum function, your doctor should tell us when asking for an appeal. IF (lol) we agree, we will expedite or make a decision sooner (within 3 working days) on your appeal.

So I guess call the Dr again make sure he got this (it shows CC him) and that he is going to file said appeal. I am nervous though like pugsy said he might not know the correct terms to use etc like the sleep dr would.....

Or should I call or write an appeal also and provide all the documentation of ResScan reports etc showing the 100-200 central and 1/4 that obrstuctive events a night>?



thanks all for all your inputs etc it really means alot

[curems]

I don't know about Medicaid or about the relative success of an appeal, and someone else here may have a better guess at what will work best, but ... My sleep doc expected a denial on my lab sleep study despite having the prerequisite conditions for it so she was prepared to order the home study rather than appeal. In this case, having the home study made me eligible for a lab titration instead of home titration which worked out better for me. Might it be quicker to get the home study which may then indicate the need for a lab study or at least a lab titration which would be approved sooner? Just a thought that it might speed things up.

Oftentimes, insurance companies end up spending a lot more money in their efforts to save. Similar situation with another test - insurance wouldn't approve for my primary, wanted the referral to come from neuro so instead of just paying for the test the first time they were asked, they paid an additional $500 for the neuro to say "yep, she needs it." Sometimes, going through the motions ends up costing them more but getting us treatment quicker.

[metsfan302]

Yea I don't know, they approved the in lab one no issues 3-4 years ago....

The home one just seems a waste as well it wont show centrals I don't belive..... I dunno guess ill have to see how this appeal goes

a titration in a lab is that a test to figure out proper pressure? seems like its not going to be needed till I get something to help with the Centrals. I dunno, guess going to call my Dr, and insurance, or maybe my orig sleep dr?

It says too I can file an appeal, I guess if the doctor is going it I shouldn't?

If I do I guess just provide my Resscan/sleepyhead reports that show the 200 centrals/50 or so obstructives a night or atleast the past months statistical/summary data?

[metsfan302]

The dumbest shit i've ever heard was said today.... on my voicemail

got a call from my doctors office, the girl informed me she has spoken with both my insurance and the sleep center.

they the insurance, will only allow a sleep study done at home

Once that is compleat, the insurance will allow one in a sleep center

The girl also said its the exact same - just like it was in a lab but at the comfort of home.

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Umm I don't really think its the same --- It Wont show CENTRAL's --- I already know I have obstructive Apnea --- Is this not a waste of money since a lab study is going to be needed?

UGGGGG WOW

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That being said. I assume I can file an appeal with the proper documentation or just leave it along and carry on like a sheep to slaughter lol

[metsfan302]

Alright the plot thickens lol lol.....

I went to med tix my local medical supply place to exchange an Amara mask for the new Amara View.

While I was there I was talking with the tech I deal with. I showed him my paperwork the reports from Sleepyhead and ResScan.

I want to thank this forum for the education I have gotten this past month or two.....

He was also amazed the amount of knowledge I had and that it was pretty cool he has never heard of Sleepyhead but loved how the reports were.

I told him what I was going thru with my insurance etc. He said well whats your Dr again I told him my old Dr's name, and the new one. He said man you need to simply call your old dr up, he is the BEST around - that yes he is cocky, bold and upfront and that seems to turn people off as he did my wife and myself. That He will fix it all. That the home study is pointless that I have all the info I need in my hand, that my sleep Dr if I called and told them what was going on would schedule me an appt and just explain that I haven't been going to him in the past year or so that I was giving up on cpap and well yea you are really concerned by these numbers and show him the report or hand him my data card. That he could prob just bypass the sleep study for now - prescribe a BiPap for two weeks, if the numbers come down great, if not then move on to a ASV - he said the BiPap Might do the job - but insurance is going to want me to 1st try the BiPap first regardless before even thinking about the asv.

So I am going to swallow my pride and call my orig sleep dr whom i have not seen in over a year if not two...... and go from there

Tune in next week for another episode of - this fat mets fan ....

[Pugsy]

Just for informational purposes...home studies can sometimes flag the centrals..it depends on which type of home study is done...the cheap basic home study or a much more involved sleep study that gathers almost the same data as an in lab sleep study. The problem is often only the "cheap" home study is done and it won't/can't catch the centrals as it really is nothing more than a pulse ox on the finger and nasal cannulas for air flow. You get what you pay for with sleep studies (just like with anything else).

Crossing my fingers that you can see the old doc fairly soon.
We know there are hoops to jump through...just want to get started jumping through them sooner than later.
I am pretty sure that a regular bipap (bilevel) isn't going to do the trick but often that is one of the hoops that has to be jumped through. If your S9's EPR would go higher than 3 we mimic a plain bilevel which is most likely what they will want to try first. When using EPR at 3 it gives a 3 cm pressure support (difference between inhale and exhale which is all that bilevel is) but the bilevel machines can offer higher pressure support the 3 cm.

[OkyDoky]

If you do decide to appeal maybe this would help your cause.
1.2.2. PM is not appropriate for the diagnostic evaluation of OSA in patients suspected of having other sleep disorders, including central sleep apnea, periodic limb movement disorder (PLMD), insomnia, parasomnias, circadian rhythm disorders, or narcolepsy.
Taken from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556918/

[metsfan302]

Well Pugsy, your Voodoo Doll worked on the Met's, your fingers crossed worked for the Orig sleep Dr Appt -

I called his office, they answered on the first ring - I ask the woman do you have 40 secs so I could give you my back story - she laughs and says go

I explain everything going on, how i was a patient and just stopped over like 2 years ago etc and everything with my Truckloads of Centrals, my AHI numbers, event numbers yatta yatta - etc and the bit about the insurance rejection - She was like WOW..... Bring your SD Card and Updated Insurance and he / We will take care of everything!@$#2 heck Yea - I should of done this from the start - I don't know if it was me being stubborn, embarrassed for stopping therapy and going to him, whatever it is or was I am going Monday!!

Looked me up, I was luckily still an "Active" patient and she got me an Appt. this Monday the 9th!!! in the Afternoon.....!!!!! There is Hope!! ;o~

Based on what the Tech was saying at my medical supply place, he was thinking I have all I need for him to move on to a Bi-Pap loaner for like 2 weeks to see if that works and if not move on to an ASV. That and the insurance wants to see that all things have not worked prior to going to the more expensive ASV....

The Tech was saying the ASV is more for Cheyne-Stokes respiration or complex apnea and that since I dont have the Cheyne-Stokes respiration stuff - the Bi-Pap might do the trick, but we will see, sometimes it will not correct them and we will need to try the auto SV - ASV whatever. I do not care if its ASV - LMNOP as long as it works!!!

I was asking about the equip / brand I will most likely end up with and what they have - of course they have both Phillips and Resmed but that my Sleep Dr is a "Phillips Guy" and that I should not worry about the bells and whistle and fancy stuff that the Resmed is pushing - that the Phillips is = to them and my Dr likes them better. That he has not seen the new Dream station stuff they do not have it yet, but has seen the Resmed new line. Guess its like Nike and Reebok?

Sorry to ramble on, there is some light at the end of this dark tunnel

[metsfan302]

I assume I should just hold off on the Appeal since I am seeing the Dr Monday? (My Orig Sleep Dr who can prob get something done)

[Heart Jumping]

What a shitty day this has started to be. Got a call from the sleep center, have had this nov 14 apt for over a month now. I'm thinkin oh cool mayb a sooner date, na not this guys luck.... Seems my insurance has rejected it and my appt has been canceled. She did say they were sending paperwork for my dr to possably appeal that decision. Fml no clue what to do now totally wrong, I so need this! Wow

I feel for you. I just went through the same thing, waited several months for a sleep study, only to be called 5 days before the study and be told the insurance company had rejected it, and that they would only approve an in-home test. Serious health problems as well as oxygen levels falling to 85% (in my own tests) did not qualify for their f***ed up requirements for an in hospital sleep study.

In my case I went nuts, and got the hospital to agree to do it if I paid for it myself, but I very lucky to be able to do that. Amazingly I had to get the supervisor to agree to that, because "we don't allow that".

Insurance companies = agents of the devil. And the hospitals are their disciples. Sorry for rant

Sad, because most of the people in the system genuinely want to help. I've learned you need to be your own advocate every step of the way, the health system in this country is more an adversarial system, than one that seeks to help.

[curems]

Based on what the Tech was saying at my medical supply place, he was thinking I have all I need for him to move on to a Bi-Pap loaner for like 2 weeks to see if that works and if not move on to an ASV. That and the insurance wants to see that all things have not worked prior to going to the more expensive ASV....

Insurance companies go through these stupid protocols without considering the waste. I once had to have a prescription filled for a medication that didn't work before the pharmacist could immediately fill the one that my doctor originally ordered, all while I waited, just because it was insurance protocol.

[zoocrewphoto]

Based on what the Tech was saying at my medical supply place, he was thinking I have all I need for him to move on to a Bi-Pap loaner for like 2 weeks to see if that works and if not move on to an ASV. That and the insurance wants to see that all things have not worked prior to going to the more expensive ASV....

Insurance companies go through these stupid protocols without considering the waste. I once had to have a prescription filled for a medication that didn't work before the pharmacist could immediately fill the one that my doctor originally ordered, all while I waited, just because it was insurance protocol.

So true. I was waiting for an appointment at my doctor's office when I overheard the doctor on the phone explaining to a patient, that she could do an annual exam OR clean out his ears, either one. But not both in the same appointment as she is not allowed to bill for separate "procedures" on the same day. It seems so stupid as the person could do both in one trip, and save time. The doctor could easily do both at one visit and save time. And the paperwork would go faster. But if she bills for both at once, she will only get paid for one.

[metsfan302]

or she could of just cleaned his ears while going the exam why even need to separate charges.

That's like charging my guests to check-in and a charge at check out (hotel)

[BlackSpinner]

or she could of just cleaned his ears while going the exam why even need to separate charges.

That's like charging my guests to check-in and a charge at check out (hotel)

Because it takes time that she will not be paid for.

[zoocrewphoto]

or she could of just cleaned his ears while going the exam why even need to separate charges.

That's like charging my guests to check-in and a charge at check out (hotel)

We aren't talking about q-tips. It was some type of flushing procedure. It takes some time, uses equipment that must be sterilized, and uses supplies. Why should she do it for free? Do YOU work for free?

I don't know about your insurance, but mine has no copay for one annual exam per year. Any kind of treatment or normal appointment has a 20% copay. Totally different billing for two different types of appointments. It makes sense to do them at the same time, but one is no copay and one is a percentage copay. They are billed separately.