Good news regarding UARS and insurance coverage (!) (?)

[ignorant1]

I have read here numerous times that a diagnosis of UARS is not recognized by insurance carriers. Specifically that UARS does not meet the “medically necessary” criterion for use of an xPAP device.

While digging my way through documents at Anthem Blue Cross, I found the following: http://www.anthem.com/ca/medicalpolicie ... 063112.htm

Especially worth noting is the section that addresses UARS:

Continuous Positive Airway Pressure (CPAP) is considered medically necessary for the treatment of:

• obstructive sleep apnea meeting the above criteria; or
• upper airway resistance syndrome (UARS) as defined by AHI (or RDI) less than 5/hr but with more than 10 EEG arousals/hr associated with increased respiratory efforts (with or without concomitant observed snoring) and increased negative esophageal pressure (more negative than -10cms H2O).

Bilevel Positive Airway Pressure (BiPAP®) is considered medically necessary when used by individuals diagnosed with obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS) when CPAP has failed.

It appears that esophageal manometry monitoring is used as a criteria to establish medical necessity - but at least this is a step in the right direction. Recognition of fractured sleep due to EEG arousals, yet in the absence of “classically scored” apnea or hypopnea events, is a step in the right direction. Maybe the days of AHI scores and desaturation events as being the primary (only?) defining measure(s) may be numbered?

[Slinky]

You are right. That IS good news for UARS sufferers w/this insurance. And it isn't surprising that it is one of the Blues which has adopted this policy.

[Linus]

Since the treatment is the same (cpap or autopap) my doctor diagnosed sleep apnea when UARS was the real issue. He said it was easier to get through the medical system.

[ignorant1]

…good news for UARS sufferers w/this insurance. And it isn't surprising that it is one of the Blues which has adopted this policy.

I was under the impression that many insurers utilize Medicare guidelines to set their policies. So perhaps Medicare has changed position on this too? I don’t know, but it’s worth researching.

…my doctor diagnosed sleep apnea when UARS was the real issue. He said it was easier to get through the medical system.

That seems to be a common way that doctors are able to get coverage for their UARS patients. Hopefully the PSG data will support the OSA diagnosis just in case the insurer wanted to dig into the claim. However, if esophageal manometry is an absolute must for the UARS diagnosis to stick, the OSA diagnosis may still be the path of least resistance. But at least the insurers may be starting to change their tune!

There are also some interesting links in the original document that address qualification for BiLevel necessity, and definitions of “failed” CPAP use (thereby qualifying a patient for BiLevel).

[archangle]

Isn't esophageal manometry a rather nasty procedure that's very rarely done?

[ignorant1]

Isn't esophageal manometry a rather nasty procedure that's very rarely done?

Yes, on both counts.

BUT this may be indicative of a shift towards recognizing the implications of UARS in general. If UARS is diagnosed via other means, i.e., respiratory effort coinciding with arousals and reduced flow (but not a hypopnea or apnea), maybe(?) insurance could be persuaded to approve xPAP coverage. However I must state once again the simply “gaming” the system with a diagnosis of OSA is still the path of least resistance – for now.