AHI Too Low For Treatment -- Where To?

[NotLazyJustTired]

I also wanted to add: Since your insurance is probably not going to pay for a titration in any event, (they didn't for me) be sure to get an APAP with full efficacy data. Have your doc script it that way so there is no confusion or arguments with the DME. The APAP will help you settle in on your needed pressures. But you will need a machine (like the S9 AutoSet) with full data capabilities to be able to see where your pressures are going. It will also help you get a handle on any leak issues.

[arnppulm69]

Ridiculous, I agree. I have gotten MANY people qualified with AHI 5, and complaint of fatigue. Especially if you have another issue such as HTN or heart disease. I agree with previous posts, have the tech reread that sucker, he may have nodded off at the wheel .

[sleepstar]

If you're willing to give CPAP a proper go, how about renting some equipment for a couple weeks to see if its for you? There are many people on this forum who would give you heaps of advice and guide you all the way.
I usually wouldn't recommend this without seeing a sleep physician and CPAP techs etc but if this obviously seems like it isn't an option for you then it looks like you need to take it into your own hands.

I really would not recommend buying any equipment until you've trialled it. It's a lot of money to spend and if it turns out CPAP isn't for you, there goes your money.

You need to be committed to trying though. If it helps you and you feel the benefits - then you can decide if you want to obtain your own machine (2nd hand and cheaper perhaps?)

[Imasnorin]

Insurance companies have gotten to the point that they are non-payers rather than payers. I have worked for 2 health insurance companies and saw drastic payment changes over the years. Most insurance companies have shareholders to make happy, how do you make a crap load of money? Don't pay claims....they know that there are some things that will not be appealed and thats what they count on. Even delaying payment saves/makes them money. Doctors and anyone in the medical profession have a good reason to dislike them.

My insurance company does not pay for a sleep study(in a lab) or a titration after you get the results. The first fact I didn't find out until AFTER it was done. I had them send me a replacement denial and it actually said that the sleep lab was not the safest place to have it done but it might pay for alternate locations, the home is what I found out is the alternate location. Funny, being in a lab and being on camera and hooked up to monitoring equipment seems pretty safe. The good news is that the sleep center admitted they screwed up and wrote it off. Whew! It was only a preliminary study and it was $4600. When they attempted to precert the titration they said they dont cover them based on my dx, go figure. My doctor said that I was his first patient like this and had to talk to a different doctor to get some ideas. The good news is that I ended up with a machine as it is covered WITHOUT a precert. Check your policy carefully, "CPAP" machines are considered Essential Medical Equipment since Obamacare and they probably cant deny it. Any doctor can write a script for the machine so you could always get the ball rolling with your primary care doctor.

Don't get discouraged and it will be worth it in the end, my OSA is considered moderate and it has helped tremendously.

[Imasnorin]

A

[Pugsy]

If you are going to end up purchasing a machine out of pocket and trying this out yourself... may I suggest the PR System One 60 series Auto CPAP model 560 (550 would also work it just doesn't have the heated humidifier option built in).

Two reasons...it won't cost as much as the ResMed S9 Autoset...and really a better reason...it will flag FLow Limitations (often seen with UARS) in a more optimal format for evaluation and same thing with snores and it also flags RERAs which the ResMed machine doesn't flag.

Check out my signature line for the SleepyHead Glossary which is actually a glossary of terminology for cpap terms in general that are seen on the reports...for the RERA definition and Flow Limitation definition.

[NotLazyJustTired]

Most insurance companies have shareholders to make happy, how do you make a crap load of money? Don't pay claims....they know that there are some things that will not be appealed and thats what they count on. Even delaying payment saves/makes them money. Doctors and anyone in the medical profession have a good reason to dislike them.

This may seem like piling on, but in my experience that is absolutely correct! Every major step in my treatment has resulted in an intitial "No" and required a concerted effort on my doctors to resolve satisfactorily.

I had extreme GERD; my fault really for not seeing the doctor years ago when it started. He prescribed Dexilant. Insurance refused coverage (it's pretty expensive); recommended OTC. I had been on various OTCs for years without effect. Two appeals later and I have my meds. Made a huge difference; no more acid reflux. I also had an endoscopy to rule out Barrett's esophogus; insurance didn't flinch on that one; test came back negative .

Insurance initially required a home sleep study. When that came back inconclusive the internalist sought pre-authorization for a sleep study. That was denied. He appealed again and won. I was referred to a sleep specialist and he set up the study. The rest of the story is in my previous post: "Medicare" apnea index below 5, no coverage. Two appeals later and I have my CPAP.

So, in my experience, the default answer for anything pricey seems to be NO, unless it is potentially life threatening perhaps. What this has taught me is that it is hugely important to find physicians who will be your advocate. But you must also be your own advocate. I don't think my sleep doctor would not have fought so hard for me if I had not stressed to him just how bad my fatigue was and how extremely important it was to get this rectified. I would have found a better doctor if he had not put forth the effort and I would suggest the same to anyone reading this.

I wish the OP best of luck and remember, we are here to help!

[MagsterMile]

[quote="49er"]I totally agree with SU about having your doctor fight the decision. It sounds like the insurance company is cheating you big time out of paying for something that should be covered.

49er

I can't help but sound off here about Aetna. I'm sure there are plenty of people who absolutely love that insurance. I hate it for how they handled my insurance claims. I had $1000's of dollars in claims that they found a way to cheat me out of payment for. I will never buy insurance from them again. I'll go without before I give them one more dollar of premium!

[KathyJL]

Well, looks like Aetna is on a roll...I got my denial letter today. I was diagnosed with sleep apnea in 2009, AHI=13. I've been on CPAP since then (different insurance), but recently visited my dentist due to ear pain, headaches, & jaw pain caused by bruxism (clenching), who suggested I get an oral appliance to take care of the apnea & clenching. I've never slept well with CPAP, so figured I'd try the appliance. Dentist submitted for pre-cert. Aetna denied because my AHI was not 15!! Unbelievable. If my AHI was >5 with a co-morbidity issue, they'd cover. I guess they'd rather have me develop potential health problems than give me what I need to breath at night. The responses to this post have been great because I'm in the same boat. I plan to appeal. However, I have a glitch...the sleep doctor who diagnosed me in 2009 is not in-network with my new insurance. Do I go to my PHP or a new sleep specialist to help me with my appeal? I plan to list all my health diagnoses in the hopes that one qualifies for a co-morbidity condition, but I don't know who to turn to to help me with the appeal. I also plan to have my dentist write an appeal letter. Any advice??

[stage0]

I have used the neckline slimmer for a year for snoring only...and my boss uses it with some improvement to snoring only. It is only for muscle tone of the neck muscles.

As to your sleep study Kathy...I usually ask/tell my pts that have a really low AHI thru the study...to sleep on their back to see them sleeping in their worst position. Like you said you sleep worst there. Go back to your testing center and see if they will do a free study based on an ineffective testing. Make sure the study did not record you sleeping supine for say an hour thru the nite.