Insurance denied ASV machine

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
silverpines
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Insurance denied ASV machine

Post by silverpines » Wed Sep 20, 2017 8:25 pm

Dx 2 years ago with an AHI of 9 mild sleep apnea and insurance allowed me a Resmed CPAP machine. After struggling for a year at 11 cm pressure I went for a 2nd opinion and a lab test (the first was at home test). My new doctor is wonderful and the new in lab study showed AHI of 16 and REM associated AHI of 40. The lowest NREM saturation was 91% and baseline was 95%. Then I had a titration study that showed AHI of zero with pressure between min 3, max 8 cm (she thinks 4cm would be about right). Insurance turned me down the first time due to my diagnosis of central apnea and the doctor did not define the criteria to determine what is central apnea so the doctor appealed. This time the insurance co.s pulmonologist turned me down for ASV due to the sleep study not using health plan oxygen values in the assessment. I'm at the point now of paying out of pocket because I want to feel better. Is it worth fighting the insurance company? I think the first doctor diagnosed me wrong probably due to the at home test not picking up the fact that I have mostly centrals. ASV sounds much more comfortable and less likely to fail at long term treatment.

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LSAT
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Re: Insurance denied ASV machine

Post by LSAT » Wed Sep 20, 2017 8:53 pm

silverpines wrote:Dx 2 years ago with an AHI of 9 mild sleep apnea and insurance allowed me a Resmed CPAP machine. After struggling for a year at 11 cm pressure I went for a 2nd opinion and a lab test (the first was at home test). My new doctor is wonderful and the new in lab study showed AHI of 16 and REM associated AHI of 40. The lowest NREM saturation was 91% and baseline was 95%. Then I had a titration study that showed AHI of zero with pressure between min 3, max 8 cm (she thinks 4cm would be about right). Insurance turned me down the first time due to my diagnosis of central apnea and the doctor did not define the criteria to determine what is central apnea so the doctor appealed. This time the insurance co.s pulmonologist turned me down for ASV due to the sleep study not using health plan oxygen values in the assessment. I'm at the point now of paying out of pocket because I want to feel better. Is it worth fighting the insurance company? I think the first doctor diagnosed me wrong probably due to the at home test not picking up the fact that I have mostly centrals. ASV sounds much more comfortable and less likely to fail at long term treatment.
I don't know of any machine that has the capability of going as low as 3. I don't recall seeing anyone on this board that could breathe with a pressure of 4. To me your numbers don't sound right. When you say you struggled for a year...what did you mean. A pressure of 11 is not really high. With a pressure need of 4, I think it will be hard to justify an ASV machine. Do you have a copy of your sleep study?

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kteague
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Re: Insurance denied ASV machine

Post by kteague » Wed Sep 20, 2017 8:57 pm

I'd like to suggest that you post copies of your sleep study reports. The info you've given so far is a bit perplexing. Was central sleep apnea not diagnosed on the first home study? Guessing the answer to that is no since a CPAP was dispensed. That would leave the in lab study as being the source of the central diagnosis. What we don't know is if the centrals were in the diagnostic portion of the study or appeared during titration. Sometimes centrals don't need an ASV. Having some centrals is not at the same level as having central sleep apnea. Insurances typically require that one fail on less expensive options before agreeing to pay for an ASV model unless the need is undeniable, and even then they may deny it at first. So, if you could provide some documentation, there are some on here who are well versed in this stuff and could give input. Also, knowing if your CPAP machine data shows centrals could be helpful.

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Pugsy
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Re: Insurance denied ASV machine

Post by Pugsy » Wed Sep 20, 2017 9:05 pm

DeVilbiss machines will go down to 3 cm.

Machines in the lab setting doing the titrations...very well could go as low as 3. They are a bit different from what we see at our end.

I am confused...when did the diagnosis of central apnea happen and how bad was it?
Insurance won't pay except for some very specific criteria needing to be met. They get real stingy when it comes to these high dollar machines.

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