Sounds fishy; insurance coverage for mouth piece but not CPAP?

[colomom]

A relative of mine who recently underwent a home sleep study was diagnosed with mild OSA. The sleep study showed an AHI of 14. The doc told my relative that his sleep apnea was likely worse than the study showed because the ahi when on his back (which had limited data) was 30. The doctor told my relative that because his AHI was mild insurance won’t cover a CPAP, but the doc thinks he can get the insurance will cover the $3000 mouth piece the doc recommends.

This situation of course set off numerous red flags for me. I plan to dig deeper and find out more info about the doctor.

My questions are in the US wouldn’t insurance typically cover a CPAP for someone like my relative who is at the high end of mild? It makes no sense to me that a $3000 dental device could somehow be covered yet the less expensive gold standard treatment isn’t. Also wondering about dental devices, can they mess up your jaw?

[Conrad]

What exactly does this $3k dental device consist of?

Sounds fishy to me. Your relative should contact their insurance company for the lowdown on this.

[LSAT]

Did someone check with the insurance about this? To me, there is something fishy about the doctor. (The mouthpiece is normally supplied by a dentist).
BE SURE to get a copy of the sleep study.

[ChicagoGranny]

The relative needs to talk to her insurance company about CPAP coverage.

[colomom]

Thanks for the input, will definitely encourage him to get a copy of the sleep study and to talk directly to his insurance company.

He’s visiting from out of town for a couple of nights and I offered him use of an extra Dreamstation2 my family has to do a trial run with a APAP for for the 2 nights he’s in town. He did pretty good last night, said it felt so natural he kept worrying the machine wasn’t on. After 5 hours it woke him up and he had trouble with it, but I figure 5 hours is pretty good. I created a new profile for him in Oscar and plugged in the SD card but I can’t figure out how to see the flow rate chart. Does anyone know how to add the flow rate chart if it isn’t there? The Dreamstation2 was a replacement for a recalled machine, but it’s never been used so I’m unfamiliar with it.

[Pugsy]

I created a new profile for him in Oscar and plugged in the SD card but I can’t figure out how to see the flow rate chart. Does anyone know how to add the flow rate chart if it isn’t there?

The SD card must be in the machine while it is being used to get the flow rate.
If the card wasn't in the machine there is no way to get the flow rate data back.

[SleepGeek]

Also wondering about dental devices, can they mess up your jaw?

They sure can.

I agree with the others that its time for a new doc.
I prefer a pulmonologist that specializes in sleep.

I never had a dental device but thought that insurance wouldn't cover any of it?
So yea, something is fishy.
What is this docs specialty?

[colomom]

I created a new profile for him in Oscar and plugged in the SD card but I can’t figure out how to see the flow rate chart. Does anyone know how to add the flow rate chart if it isn’t there?

The SD card must be in the machine while it is being used to get the flow rate.
If the card wasn't in the machine there is no way to get the flow rate data back.

Thanks Pugsy, as always you’re amazing! I thought I had the SD card inserted correctly last night, but with the Dreamstation2 the spot to insert the card is hard to see and awkward. When I first pulled the SD card out of the machine this morning nothing was on it, but I reinserted it and got most of the data minus the flow chart. I’ll be sure to make sure it’s inserted correctly tonight!

[Janknitz]

I never rely on a provider who is going to make money on what my insurance will cover. Your relative should contact his insurance company and request the "Evidence of coverage". This is the actual contract between him and his insurance company, although he's probably never seen it. It will say exactly what the coverage criteria is for CPAP or an oral device (oral devices are very rarely covered by insurance). If he's on Medicare, then regardless of what his secondary payer says, Medicare guidelines apply, and CPAP can be covered with a 14 AHI based on symptoms.

https://www.cms.gov/medicare-coverage-d ... &NCAId=204

AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.

[colomom]

As many of you and I suspected, the doc who said only a mouthpiece will be covered is an oral doc who will profit off the mouth piece. To be fair, knowing my relative I think he sought out an oral doc because like many the idea of a cpap for him was difficult.

The trail run I offered my relative with my extra Dreamstation2 was incredibly successful! He slept better with APAP than he has in a long time. His biggest complaint was that the few times he woke up he thought the machine wasn’t working because it felt to him like normal breathing.

His plan now is to get the mouthpiece the oral doc recommends to use when he travels and also pay out of pocket for an APAP that he will use at home. I’m bummed that he in my opinion is wasting money but understand that like for so many there is sadly a stigma associated with cpap use, so for now at least he can’t get over the hump of using a cpap for his business travels.

So thankful for the incredible knowledge I’ve learned from this forum! Pretty amazing that because of that knowledge I’ve learned here I was able to dial in settings and fit a mask out of the extras I had laying around to allow my relative the best couple nights of sleep his had in years!

[chunkyfrog]

There is the possibility that your relative would prefer to do ANYTHING to avoid cpap;
and is not being truthful with you.
It happens all the time.

[SleepGeek]

His plan now is to get the mouthpiece the oral doc recommends to use when he travels

Ya have to wonder IF he will be able to sleep with that device in his mouth torqueing his jaw - I doubt I could.
afaik there are No refunds.

I know, for sure, I would never trust a doc who lied to me.
How was he planning to recover his money when the insurance didn't pay?
I'm sure he did have a plan.

[Pugsy]

Ask your friend how will he know IF (big if) that mouth piece does its job preventing the apneas.

[loggerhead12]

The trail run I offered my relative with my extra Dreamstation2 was incredibly successful! He slept better with APAP than he has in a long time.

That will be a huge contrast to the mouthpiece. I tried that route. They are extremely uncomfortable and make you drool like crazy.

[colomom]

Thanks for all the great advice!

Night 3 of using my extra cpap was again very successful. My relative is driving back home today and was happy to have a good nights sleep with the cpap prior to the very long drive.

He’s 100% sold on cpap. He took the mask I had him try that he likes home and with my help is going to have his doc fax in a script so he can order an out of pocket machine on Monday. He loved the brief time he used the cpap and plans to use his new machine when he is at home. He’s hoping that his wife will be cool with him moving out of the guest room with the cpap controlling his snoring

Unfortunately despite discussing the many valid concerns many of you have raised regarding a mouth piece, he’s hell bent on trying it as well. I’m surprised he can’t see that this doc is clearly a shister who is taking him for a ride. I guess sometimes we see what we want to see. While he recognizes cpap is what he needs and is willing to pay out of pocket to get a machine (which likely isn’t necessary) somehow he still can’t let go of the hope that a simple dental device could possibly also fix the problem.