Insurance woes

[cpapnewbiw]

Hi everyone,
I've been having major problems with my insurance. I definitely have OSA - confirmed by a sleep study in 2011 and another, less accurate, home study earlier this year.

I've been to two ENTs and both have requested titration studies to see what settings I should have for my CPAP. Both attempts have been declined as "not medically necessary." My insurance is apparently very disinclined to approve these studies unless I have some additional problem, like being overweight or suffering from major problems. I'm relatively young, not overweight and mostly healthy.

The next step my current doctor has taken is to request an AutoPap, but I'm so disheartened by dealing with my insurance here. I need help. I'm tired all the time, not sleeping well and worried that this will never get fixed. I've been fighting this battle for almost six months now.

Will an AutoPap even help? Is there one that you guys suggest? I'm frustrated I have to even consider buying this equipment myself but I don't know what to do. I'm always exhausted and it can't just be because we're new parents. I go to bed at a decent time and I'm still dozing off a few hours after waking up. It's really affecting my life.

Any help would be appreciated.

[Pugsy]

Will an AutoPap even help?

There's a real good chance it will.

Is there one that you guys suggest?

Without knowing the pressures needed ahead of time. I would suggest the ResMed AirSense 10 AutoSet or AutoSet for Her or the Respironics DreamStation Auto CPAP.
Of the 2, I would suggest the ResMed as number one mainly because if you end up needing higher pressures in the teens I think that ResMed's exhale relief might make things a bit easier to manage.

If insurance won't pay anything and you end up having to foot the entire bill yourself and money is tight...there are ways to get a decent machine from the secondary market.

[Sheriff Buford]

You state that you have sleep apnea, but others appear to day otherwise. What was your AHI on your sleep study? I'm hoping you may have another sleep disorder that can be fixed.

Sheriff

[robysue]

cpapnewbiw,

Can you clarify: Is your insurance refusing to pay for a CPAP titration study or a CPAP machine itself? Some insurers and HMOs now prefer to set up a recently diagnosed OSA patient with a APAP set wide open and let the APAP do the "titration" to determine pressure needs rather than doing a formal titration study.

If your insurance won't pay for either a CPAP titration study or a CPAP/APAP machine, you need to find out exactly why they think these things are not medically necessary. Go back to your diagnostic studies: What was the diagnostic AHI? What was the breakdown of events? And did you have desats with the hypopneas that were scored? And are you covered by Medicare or Medicaid? They have special rules to determine coverage that can inadvertently affect a small number of people with OSA.

Since the doctor is willing to right a script, you could also opt to pay for everything out of pocket. There are sources, such as secondwindpap.com where you can buy reliable used equipment for less than the cost of brand new equipment. Buying new online equipment will be cheaper than buying it at a brick-and-morter DME.

[Pugsy]

Previous thread might help clarify things.
viewtopic.php?f=1&t=114165&p=1104462#p1104462

It appears that a diagnostic home sleep study has been done recently and OSA is the diagnosis but the insurance won't pay for an in lab titration study.

Be careful when reading the first thread. OP was calling the titration study to find pressure needed as the diagnostic study and it was a bit confusing.

[chunkyfrog]

The OP first came here in OCTOBER, and was given ALL THE SAME ADVICE.
So, what has happened? Was he hospitalized?
Why does he still not know if insurance will cover the machine?
Can we all agree that is time to DO SOMETHING.
Even if the expense is out of pocket, your health is the best possible investment.

[bigdave36]

This kinda happened to me. I had a home study then a titration study. at a pressure of 13 all the apneas were not taken care of so the sleep lab recommended another titration study.
Instead my doctor ordered an Airsense 10 VPAP with pressures set at 5/15.I been at it 3 weeks and it seems to be going pretty well with my AHI above 5 only a coupla a times. I tested at a moderate level of 15 30 events per hour,
Good Luck

[Pugsy]

A word about bypassing the formal in lab titration sleep study which is used to determine optimal therapy.
Sometimes it works great and sometimes it doesn't work out so great. There are pros and cons to doing the in lab titration study but it seems like more and more insurance companies are going to the "let's give them and apap machine and see what happens" mentality because it saves them money.
Most of the time using an apap machine to dial in pressure needs will work well for the majority of people who have only plain OSA to deal with. This is what insurance companies are looking at and they reserved the in lab titration studies for people who end up with some sort of complicating issue.

Kaiser has done this for years and it seems like more insurance companies are going in that direction.

Get a full efficacy data apap machine (avoid the ResMed AirStart at all costs) ....finding optimal pressures is fairly easy and really doesn't take all that long. Should you be in the minority and come up with some sort of complicating factor that is usually easily seen on the data reports available from a full efficacy data machine and then they can be addressed via an in lab study if needed. Most of the time it isn't needed for people with plain jane vanilla OSA.

BTW...I had an in lab titration sleep study and they didn't/couldn't come up with optimal pressure settings because I had great difficulty getting decent sleep. I ended up doing my own "titration" study with my apap at home and got my settings dialed in fairly easily. Sleeping in the in lab setting comes with its own set of potential issues that can cause less than optimal results. Getting to sleep and staying asleep with all the wires AND the mask can be a real challenge and if you can't get good sleep they can't even come close to finding the right pressure settings. It's one night in a foreign environment and we don't sleep the same every night anyway.
At home, in your own normal setting, with your own pillows and your own bed, will give you a greater chance of getting the sleep needed so that optimal settings can easily be determined.

Don't be afraid of using the APAP to find the optimal pressures needed...it's really fairly easy to do and if you do end up being someone with some unusual situation going on the in lab study can still be available.

[cpapnewbiw]

You state that you have sleep apnea, but others appear to day otherwise. What was your AHI on your sleep study? I'm hoping you may have another sleep disorder that can be fixed.

Sheriff

I have severe OSA. The insurance seems to want more than "just" OSA to give me the machine.

[cpapnewbiw]

The OP first came here in OCTOBER, and was given ALL THE SAME ADVICE.
So, what has happened? Was he hospitalized?
Why does he still not know if insurance will cover the machine?
Can we all agree that is time to DO SOMETHING.
Even if the expense is out of pocket, your health is the best possible investment.

My apologies for the repeated question - I've been at this SINCE AUGUST and I'm really at a loss. My insurance has declined the titration study and we are now waiting for the doctor to get in touch with them for an AutoPap.

I think you're right, though, and my only option at this point is to buy an AutoPap.

[cpapnewbiw]

cpapnewbiw,

Can you clarify: Is your insurance refusing to pay for a CPAP titration study or a CPAP machine itself? Some insurers and HMOs now prefer to set up a recently diagnosed OSA patient with a APAP set wide open and let the APAP do the "titration" to determine pressure needs rather than doing a formal titration study.

If your insurance won't pay for either a CPAP titration study or a CPAP/APAP machine, you need to find out exactly why they think these things are not medically necessary. Go back to your diagnostic studies: What was the diagnostic AHI? What was the breakdown of events? And did you have desats with the hypopneas that were scored? And are you covered by Medicare or Medicaid? They have special rules to determine coverage that can inadvertently affect a small number of people with OSA.

Since the doctor is willing to right a script, you could also opt to pay for everything out of pocket. There are sources, such as secondwindpap.com where you can buy reliable used equipment for less than the cost of brand new equipment. Buying new online equipment will be cheaper than buying it at a brick-and-morter DME.

They're refusing to cover the titration study. We are only now entering the battle to get the AutoPap approved. That' been bungled because my 2011 sleep study center put down the wrong date of birth for me (which the new center just noticed) and that needs to get fixed first.

The short version is that our insurance sucks - they want the person requesting the titration study to have more than just OSA. In the fine print, they expect the person to have a high BMI or history of some other ailment in order to approve the study. I am hoping that the APAP gets approved, because I'm really struggling here. Not feeling alert or awake and not sleeping well at all.

Thanks so much for your help.

[cpapnewbiw]

Previous thread might help clarify things.
viewtopic.php?f=1&t=114165&p=1104462#p1104462

It appears that a diagnostic home sleep study has been done recently and OSA is the diagnosis but the insurance won't pay for an in lab titration study.

Be careful when reading the first thread. OP was calling the titration study to find pressure needed as the diagnostic study and it was a bit confusing.

Sorry about the confusion! New to all this. Appreciate any help.

[cpapnewbiw]

FWIW, I have the vendor coming to set up the APAP tomorrow - need to rent it in the meantime until it all gets sorted out. Health comes first. Will keep everyone posted, if it's of interest.

[Pugsy]

Word of caution...

Make sure that if the machine is a ResMed machine that it doesn't say AirStartanywhere in the model name.

ResMed AirSense 10 Autoset...that's okay (note the "Sense" part)

AirStart 10 models are bare bones basic machines and don't gather the level of detail that you will be needing or wanting.
Avoid anything with "Start" anywhere in the model name.

Respironics machines...in the apap line...that would most likely be the DreamStation Auto CPAP and it's a full efficacy data machine.

When in doubt about what model you might have...get the model number off the blower and ask us...and we can tell by the model number.

[cpapnewbiw]

Word of caution...

Make sure that if the machine is a ResMed machine that it doesn't say AirStartanywhere in the model name.

ResMed AirSense 10 Autoset...that's okay (note the "Sense" part)

AirStart 10 models are bare bones basic machines and don't gather the level of detail that you will be needing or wanting.
Avoid anything with "Start" anywhere in the model name.

Respironics machines...in the apap line...that would most likely be the DreamStation Auto CPAP and it's a full efficacy data machine.

When in doubt about what model you might have...get the model number off the blower and ask us...and we can tell by the model number.

Will do! Thanks, everyone. Sorry if I've broken protocol - new to the board, but very appreciative of your help!