Preparing my case for a medically necessary Autoset

[Kilgore Trout]

I'm armed with my weapons...

Data:

• reports of stats of my last week of 10cm, available as stats
• reports of stats of the 3 weeks before my last at 13cm (prescribed), available as stats
• reports of stats of the last month in full, available as both stats and graphs
• everything generated out of ResScan so I don't have to debate any doubts of SleepyHead (which on comparison is rock solid (and way friendlier))

Arguments:

• If my leaks and AHI were about the same (slightly better) at 10 than they were at 13, I'm led to believe I would get the best care if I'm able to use auto for a few nights in a row to verify what pressure I need.
• Any changes in pressure, I can email them a report of the Auto period for their records
• Any changes in pressure, I can email them a report of the CPAP period between Auto periods for their records

Hope this goes well. I'm guessing I'll get yelled at (again) for reading my own data, but I'm trying to be optimistic that at the very least, I'll give him some food for thought. For all I know, they won't look at any of the reports since they weren't generated in-house (they can't read ResMed data...?) or from the DME.

Wish me luck!

[LSAT]

I think it's your insurance company that needs to be convinced and you will need your doctor to win that battle. I think the DME will be happy to sell you an additional CPAP, but who will pay for it?

[Kilgore Trout]

I think I was prepared to be shot down, but I wasn't prepared for the lunacy that ensued. It's pretty funny.

In all fairness:

1. Ultimately the doctor said he thinks APAP machines aren't capable of good treatment, and haven't been since '85. That's his medical opinion, and I have to respect his refusal to document it being medically necessary. He's doing what he believes is right, and I can't argue with his decision. I can disagree with his point of view, sure, but the guy has scruples.

Now for the funny parts:

2. He refused to agree that APAP machines have gotten ANY BETTER in the last 25 years.

3. He told me I only wanted an APAP machine because I'm buying into corporate propaganda, and "the sleep community is against them." (only the first part is funny; I have nothing but his word to go on about the second part)

4. The office, American Sleep Medicine, refused to read my card, because it's from a Resmed machine. They have a contract with PR, and they're not allowed to read cards from anything else (wait... I thought I was the one being pushed around by corporate propaganda!).

5. When I presented a USB thumb drive with the reports in PDF format, the office staff claimed they couldn't read it since they couldn't open it with Notepad. Seriously... in 2012, who can't open a PDF?!

6. The doctor requested I print out and mail him the reports from ResScan. I said, "why don't I just email them to you?" "No, we need print outs." Seriously? I guess I shouldn't expect much from the office that can't cope with a PDF.

7. This quote from the doctor: "You're not going to convince me, and I'm not going to convince you. You have the experience of one patient, and I have the experience of thousands." That was the response that I review my data a few times a week, and I know what's working for me.

8. When I told him I set my pressure from 13 to 10, and as a result, my AHI improved slightly, and my leaks 95% percentile dropped substantially, his response? "I think you should go back to 13." I commented that he based that diagnosis off me being covered in electrodes, in a weird bed, wearing a mask for the first time, and freaking out a little, and I'm basing mine off watching my numbers carefully almost every night in the setting I'm most comfortable in.

So, that's my morning. My issues are that I'm dealing with an inefficient office staff, a doctor who won't consider anything outside of a lab titration, and that American Sleep Medicine isn't a doctor's office. It's a company that has doctors on staff. I don't think with this setting I'm getting the best care for my insurance company's money.

If they could have said anything different... even that I shouldn't go auto, but just let them know within a day of changing my settings and how it's affecting my numbers... I would feel different. But the response was "I prescribed 13. You should be set to 13. I don't need to see your machine's reports to know that."

So, calling a buddy's sleep doc today, and making an appointment there. To be honest, I don't care about the auto machine. What I do care about is a doctor wanting to work with me to find my right combination of comfort and good therapy.

[msradar65]

Remember your doctor works for you..not you for the doctor. I would change doctors. Its apparent this doctor is not willing to work with you.

[Pugsy]

But the response was "I prescribed 13. You should be set to 13. I don't need to see your machine's reports to know that."

Unfortunately typical doctor "I am God and walk on water" syndrome. He would be my former doctor.
Stuck in the 80's mentality. Closed mind and all that. Time to shut the door on him and move on to find someone who actually cares and will listen to you.

[chunkyfrog]

Amen.
Changing a doctor is no big deal; and way more important than changing your mechanic, electrician, or grocer.

[Janknitz]

1. Why do you need the doctor to certify "medical necessity"??? The insurance company DOESN'T CARE!!!!!!!!!!! If you need an E0601 machine, they'll pay for an E0601 machine, auto or not.

2. Dump the DME, go to any other DME who WILL provide an E0601 machine that happens to be auto.

3. Ask another doctor to write a specific script if you keep running into roadblocks with this paternalistic uninformed A**hole!

4. Find a new sleep doctor who will work collaboratively with you for your optimal health instead of his own ego.

[BadThad]

WOW! That is over the top. I'd definately seek a new doctor. For that matter, you might be able to show the data to your regular phyiscian and convince them to change to APAP. Your prescription can come from ANY doctor with a medical license. I recently decided to get a new machine and I simply talked to my GP about it and she wrote out a prescription for me with all the details. This saved me from having to make an appointment with my sleep doctor and avoid their ridiculous charges. In fact, my GP didn't charge me at all because all of my correspondence was by email, phone and fax. It's pretty amazing she didn't charge me or my insurance a dime.

Your experience should be a lesson to anyone going in for their first sleep study. I educated myself well before doing my study so that I could get exactly what I wanted, i.e. APAP with humidificaiton. During the study I keep complaining of "dryness", that led the tester to add humidity (viola, it's on my prescription). Then I complained the pressure was too high and then too low (many times) during the study and the tester changed to APAP (viola, it's on my prescription). It's just a game and you have to know how to work the sleep study to your advantage.

[LSAT]

1. Why do you need the doctor to certify "medical necessity"??? The insurance company DOESN'T CARE!!!!!!!!!!! If you need an E0601 machine, they'll pay for an E0601 machine, auto or not.

2. Dump the DME, go to any other DME who WILL provide an E0601 machine that happens to be auto.

3. Ask another doctor to write a specific script if you keep running into roadblocks with this paternalistic uninformed A**hole!

4. Find a new sleep doctor who will work collaboratively with you for your optimal health instead of his own ego.

It looks like he has been using his S9 Elite since May...7 months. Why would any DME exchangeit after that amount of time. If a doctor wrote a script for an auto the Insurance Company Insurance company would resist.

[Janknitz]

It looks like he has been using his S9 Elite since May...7 months. Why would any DME exchangeit after that amount of time. If a doctor wrote a script for an auto the Insurance Company Insurance company would resist.

Sorry, forgot that part. You may be out of luck on insurance coverage anyway. Most likely they are only required to provide you with ONE E0601 machine. The insurance company is essentially blind to the difference between APAP and CPAP and won't feel obligated to give you a second of what they consider to be the same thing (even if we know differently).

You are going to be banging your head against a very hard brick wall. If you possibly can, you'll be SO much happier getting your own APAP (online or used). The fight is going to drive you NUTS!

[Grand-PAP]

Hi Kilgore,

I sent you a PM.

[MDALE]

A minor side point - the reason they insist on a printout and can't open a pdf, accept e-mails or thumb drives is simple. They do not want to risk a computer virus.

[Breathe Jimbo]

Now I know why your moniker is familiar. I just read Slaughterhouse-Five.

[LinkC]

If you have a NEW 'script that specifies APAP, your insurance has to provide it; regardless of how long you've had the old machine.

I was 2 months in and got a new APAP script. Neither the DME nor Ins balked at all. I DID have to pony up another co-pay, of course.

[BlackSpinner]

A minor side point - the reason they insist on a printout and can't open a pdf, accept e-mails or thumb drives is simple. They do not want to risk a computer virus.

Then they should get good anti virus software. Or switch to Linux.
It is not a valid excuse.