Newly Diagnosed rant. BCBS MA denying titration study

[sonnet]

This is my introduction - and my plea for any advice/ info. The short/TLDR version is it looks like BCBS in MA anyway is denying CPAP titration studies. - I think in favor of an APAP trial. at home But I'm not sure and I'm extremely wary given how Things have gone for me so far. I just don't trust the "healthcare system" right now. At all. Looking for any input.

So here's the background. I was recently diagnosed with severe sleep apnea (AHI =33). This was after:

1. Having a lab sleep study in 2002 that showed moderate sleep apnea, but which results my doctors never informed me of.

2. After going more than a decade sleeping all the time (I average 11 hours a night - up to 15 on weekends), tired all the time my doctor sends me for another sleep study, but this time BCBS insists its a home study. I know it's a bad study, because the strap on the chest doesn't work with my bust size and shape, and every time I wake up,things are unplugged. Study comes back positive for hypoxia, but negative for apnea. The sleep doctor and my PCP are both fine with that. Neither look at my 2002 results.

3. My psychiatrist is not fine with it. After me complaining for another year how much I sleep and how hard it is to get through the day he insists I see the sleep,doctor who read my study because the results don't make sense to him.

4. The sleep doctor says that the home study must be a false negative because he's now finally looked at the 2002 results. This appointment is the first time I find out about them. When I ask why noone ever told me, he shrugs. This time BCBS
Agrees to pay for a lab study - where I'm finally diagnosed AND told about it after 13 years.

5. I'm supposed to have A CPAP titration study. BCBSMA - well actually this company they've outsourced sleep study authorization to - American Imaging Management - denies the titration study. The explanation is I can't have a titration study unless I have chronic lung disease or chronic heart failure. There's a fat policy included with No explanation of how I'm supposed to get CPAP. I email my doctor's office. No response. I call BCBS and AIM and all I'm told is that a CPAP titration study is not medically necessary, and if my doctor wants he can call. I - as the patient - don't have a right to know anything more than that.

So I don't have much choice but to look up AIM on the web. They look like they're about hard-core management of sleep studies and CPAP. Monitoring compliance through your CPAP machine so that the insurance company can deny payment if you don't use it enough. Making sure people have home sleep.studies wherever possible (yeah, worked real well for me).

And finally, buried in there I figured out why they're denying a CPAP titration study. They want me to do an APAP trial instead, I guess at home, which will tell them, I guess, what pressure I need. Hopefully.

I have no idea if this is a good idea or not. But given how the home study went - I'm incredibly dubious. Because of that damn home study I went another year exhausted and sleeping my life away.

1. Anyone know anything about using an APAP trial for titration?
2. Anyone ever deal with AIM before? What's the situation with the compliance monitoring? What if I have a hard time adjusting or the first masks or machines don't work for me - any allowance for that? Do I get to select my own machine and DME or will they force me to get the cheapest one available. Etc.
3. Any other advice or thoughts?

[palerider]

1. Anyone know anything about using an APAP trial for titration?

search.php?keywords=%22home+titration%22

many consider it a better judge of what you need than a few hours in strange conditions with wires strapped all over you.

[chunkyfrog]

My suggestion would be to get an autotitrating machine and get on with it.
Home titration can be less traumatic and more accurate than lab processes.
Many insurance companies accept this as SOP.
You will want a full data autotitrating machine for keeps anyway, as your pressure needs may change in the future.

[bwexler]

Sorry the system has put you through the ringer. It is all too common here.
Although an AHI of 33 is considered severe, its at the low end of severe. I am kinda in the middle with AHI of 84. Several of the folks here are well over 100.

It is becoming a standard practice to do a home titration for those diagnosed with straight obstructive sleep apnea.
The best solution is for you to educate yourself on the auto titration PAP machines. If you read through the stickies at the top of the forum, you will learn more than your insurance rep and equipment provider (DME) combined.
My personal recommendation would be to insist on a Resmed Airsense 10 Autoset for Her, second choice is the A10 Autoset. Then you can accept a Philps RespironicsDS560 Autoset or the recently discontinued Resmed S9 Autoset.
Any of these machines will do a fine job of titration at home, as long as you also download the free Sleepyhead software so you can retrieve the mountains of information these machines will provide.
There are many experts here who will be happy to assist you with deciphering the information and using it to adjust the equipment to your needs.
An in lab titration is one night in a strange bed. Any of the Autoset machines will adjust the your needs breath by breath for as long as you use the machines.

The hardest part other than fighting the system, is finding the right mask for you. Everyone can tell you what they like best. No one can tell you what you will like best. It's kinda like shopping for women's shoes.

[SewTired]

First, I know you are doing better this time around but you should insisted on knowing results in 2002. That's all water under the bridge now. Since they have decided on th err APAP study, follow through and be sure you make a follow up appointment now if you want your insurance company to pay. If you want to go the out of pocket, which requires no compliance, your psychiatrist could actually write you a script for the machine you want. That's how an extended family member got her machine.

[Janknitz]

Personally I'm a big fan of APAP titration at home. Instead of a one itchy snapshot under very unusual sleeping conditions, you get a week in your own bed and sleeping conditions. It makes a great deal of sense. My untreated AHI was 79 and my O2 sats went down to 72, but the in home titration was very effective.

It also gives you a chance to iron out issues with the mask and machine when you still have a helpful person to work with you.

Don't dismiss it out of hand, IMHO it's superior to a lab titration.

[ChicagoGranny]

I just don't trust the "healthcare system" right now. At all.

A great reason to do your own titration at home. Get it on!

[SunnyBeBe]

I have BCBS too and I'm not sure how they covered mine, but they did. Perhaps, it's because I have Type I diabetes, but I would try the at home alternative that has been suggested here.

I will add that getting my cpap has been like an act of congress. The medical equipment rep reviewed all of it with me and man....it's rather intimidating. I have a lot to prove with my compliance and if it's not to the satisfaction of BCBS, they won't pay and I have to turn the machine in or pay for it out of pocket. She could give me no cut off date that they may go ahead and pay out. ALSO, I have to pay this Medical equipment company a monthly monitoring fee so they can report to BCBS. No idea how long that will last. And I got the impression that I'm also under surveillance on my long term compliance and if that isn't good enough, they won't pay for my supplies.

[ChicagoGranny]

I have BCBS too

BCBS is an association of 37 different companies. The OP is in MA, so the two of you are using different companies that have different policies.

[sonnet]

Thank you all for the really helpful replies. You've all not only set my mind at ease - but made me happy that I'm having an in home titration. Thanks also bwexler, for suggesting Pap machines. It's intimidating how much there is to learn - but that part feels like the most intimidating part, figuring out which machine I want or can get.

Sewtired, i know now I should have pushed to find out my results in 2002. But I thought I hadn't slept at all in the study so I didn't think there were any results. I must have dozed off enough for them to diagnose it. I also didn't think I had apnea at the time so I didn't pursue it.

Also at the time I totally trusted my doctor. Now I'm totally suspicious. I had a friend who just died of cancer which had gone misdiagnosed for a year while she was in pain and losing weight.

I'm seeing the sleep doctor tomorrow and I wonder what he'll say about the in home titration. He's the head of the sleep lab so I'm guessing he'll be against it.

[sonnet]

I saw the sleep doctor today. First thing he said was "you need a titration study." So he was clueless about the denial. Or my many emails. I explained to him the situation and he said that he prefers lab titrations, but he'd just prescribe an APAP instead. I said, "for a trial?" And he said no, but after the first few weeks they'd adjust the range.

I let him fax the scrip to the DME because he did want to prescribe the Resmed 10 Airsense auto. He said S10 but I think it's the same one. I forgot to ask about whether I should get "for her". Is there really a difference? Because I'm pretty sure it will be impossible with that office to get him to rewrite the prescription. Unless I want to wait until the next appointment in 3 months.

He also prescribed the Quattro full face mask which I think was the one I'd researched and wanted to try first. Hopefully it's the same model.

At the end I told him it was really frustrating dealing with his office and he said sorry and that hopefully it will get better. But he clearly didn't care.

I like the guy fine, he seems to know what he's doing medically, but I really can't deal with an office that just doesn't respond when you need help, and where you basically have to wait till your appointment in three months to get anything done.

My major concern is that BCBS will deny something here - the DME, or prescriing APAP without a trial or whatever. If that happens I'll have to wait until September it looks like.

[Krelvin]

I let him fax the scrip to the DME because he did want to prescribe the Resmed 10 Airsense auto.

But you did get a copy of the script right? If not why not? You are legally entitled to it.

If you have the script, you know exactly what he wrote on it/them.

[sonnet]

But you did get a copy of the script right? If not why not? You are legally entitled to it.

If you have the script, you know exactly what he wrote on it/them.

No, I was thinking about it, but the medical assistant who was checking me out and had the script was impatient and I chickened out. Stupid.

[sonnet]

More fun - I just got a notice from BCBS saying that I am responsible for the $3300 for the first sleep study because there was no referral from my primary care doctor. My head is about to explode.

I actually did check before the sleep study and I actually have an email chain from th sleep lab where they say that the sleep doctor's office called BCBS and was told by Julie H yhat there was no auth for required for the procedure. I hope that gets me somewhere but the way everything's been going with this whole mess I'm pessimistic. And I know I won't get any help from the sleep doctors office.



And I know it's just going to go downhill from here trying to get them to pay for the CPAP. I know they'll deny something - the APAP, the particular machine, the DME, or compliance will be an issue. Something.

[Cardsfan]

I would call my insurance co and have them mail me a written explanation of what is covered, what needs pre approval, what you are responsible for, etc. concerning DME and anything to do with diagnosing and treating sleep apnea. Did you know you needed a referral from the primary care dr?