Another Sleep Study to get BiPAP

I've been on CPAP for about six weeks and it is not working for me. My pressure setting is 15 and I can not fall asleep easily and swallow a large amount of air that makes me feel bloated. I've tried a chin strap and wedge pillow and it does not help. My doctor says that I have to have another sleep study for my insurance to approve a BiPAP machine.

I've been billed $3,500 for the first sleep study to determine if I have sleep apnea, $3,200 for a second study to determine if the sleep apnea can be reduced with CPAP, $2,200 for the doctor to read the results of the two studies and $300 an office visit. Do I really have to go through another sleep study just so my insurance will pay for a BiPAP or am I being taken for a ride? Thanks.

P.S. I'm at my ends wits and I'm about ready to give up. I sleep much better without a face mask, chin strap, wedge pillow and a wind tunnel blowing in my face.

I went down the same path as you are...started with CPAP, too much air swallowing...told my sleep doc, and he just changed my script to BiPap for my DME...we sent my insurance a memo from my doc saying that my CPAP trial failed due to severe Aerophagia, and that was it...my DME swapped out the CPAP for a BiPap, I went on BiPap therapy, and it has been much better!

wishfulthinking wrote:My doctor says that I have to have another sleep study for my insurance to approve a BiPAP machine.

First, I hope that the amounts you are quoting are pre-insurance adjustment and co-pay.

Second, do a search through some of my posts - there are a couple on what the requirements are for most insurance companies to provide a BiPAP. I'm not in the business, but from all of what I've read that seems very, very unlikely. You basically just need to "fail" CPAP, show that you've complied with trying the therapy, have a high pressure, and have the doctor recommend it.

While it's remotely possible that an insurance company might demand another study, I seriously doubt it - the numbers don't work for them, since the study costs more or less as much as the machine. About the only way I can see that happening is if the study is a couple years old or you've had a material change in the underlying condition, but if you've only been on CPAP for six weeks that doesn't sound right. For that matter, I'd be surprised if the insurer even covers a third one in that short of a time period.

I'd check in with the insurer to find out the requirements, and if you find that they are what I've just mentioned, you probably want to both report the doctor to them and find both a new doctor, new sleep lab, and new DME to work with on the process of getting a BiPAP. Chances are the doctor has a financial interest in the lab, which is fine...but running unnecessary procedures constitutes insurance fraud, and while I'm no fan of insurers, I'm even less of a fan of crooks.

Absolutely make sure you get another medical professional to review and understand his reasoning for this being medically necessary before you take the reporting step though, since we don't know all the details and if you go down that path, you'd best make sure you have everything lined up before declaring war.

A doc is naturally going to want to see a bilevel titration so he/she knows what pressures to prescribe for you, but it might be cheaper and better for everyone in the long run to just give you an auto-bilevel and let you self-titrate. It might be worth asking about that option. That's my non-pro opinion, anyway.

jeff

I don't know all the ins and outs of your insurance system but i can relate my personal experience. I had one study that diagnosed a problem then a second that trialled cpap that only got rid of about a 3rd of my events and left the rest as they were centrals. That was enough for my Doctor to say that i needed a Bipap SV, it was data capable and the data actually showed my results were worse but even that was enough to be able to guide the next step- i was sent home with another machine to trial a resmed avaps adapt SV and all of a sudden i have gone from an AHI of 98 to an AHI or 0.4 and an AI of 0. I was beginning to think that my results were so awful that i really needed another study with the SV type of machines if we were going to get the results even close to right but in actual fact the data on the machines made that possible- it just took a little patience.

as for the comment that you can sleep fine without anything, please know that that is true for many of us but that does not mean that you are getting good quality sleep and that you are not living with increased of cardiac damage, stroke, memory problems, reflux, urinary problems, erectile dysfunction, etc etc. once you get a system that works well for you you will not want to do with out it. I am really new to all of this and i am already very attached to my bedside buddy

Thanks for the useful info and encouragement! I'm still waiting for the doctor to call me back, but the DME said her experience was that it was not unusual for the insurance company to ask for another sleep study. Seems like a waste of money to me since my study is less than two months old and there is no way I can continue using regular CPAP.

The sleep study costs don't sound out of line given costs can vary from one area of the country to another. BUT - the doctor's charges sound GREATLY excessive!!! Even allowing for the difference between the billable amount and the insurance allowed (contracted) amount. I had a recent bi-level titration at Mayo Clinic in MN and the sleep doctor charges weren't anywhere near the prices you quoted.