Sleep doc says APAP not medically necessary

[Uncle_Bob]

A while back i purchased my own APAP machine after some discussions about my high AHI with my sleep doctor. I basically had to persuade him to write an Rx and I had to state that i did not want to return my existing CPAP to his (part owned) DME. Since having my APAP my AHI has dropped to about an average of 3 and my AI is mostly zero
Normally my insurance will cover a new machine every 3 years but it has been less that one year so i did not bother with a claim. However i have since found out from someone in human resources that insurance will cover the cost of the APAP if the sleep doc writes a letter saying it was medically neccesssary.

You guessed it, sleep doc does not want to write me the letter, he has a problem with it and will not say what.

So I'm wondering what he may have a problem with? Any ideas?

[SleepyT]

Follow the money trail...it's usually about that! Are you going to find a new sleep doc?

[scrapper]

Why not have a frank discussion with your sleep doc? It seems like you have objective proof contrary to his opinion. If you cannot agree and you feel strongly, change doctors. The facts appear to be on your side.

[Uncle_Bob]

I will follow up if and when I decide to see him personally although i doubt he will change his mind. Up until now i've been dealing through the medical assistant. He stated that he was against APAP right from the start.

As for changing doctor i'm beginning to feel that i already have. I feel I have become my own doctor.

[timbalionguy]

Sounds like this doctor cares more about little rectangular green pieces of paper more than the well-being of his patients. I wonder if he tortures puppies, too? That's about the same level of compassion.

I hope word gets around about this and he is soon looking for new employment-- maybe as a security guard or bouncer.

[Pad A Cheek]

Uncle Bob,

You can always ask your regular doctor to write a script for the APAP. It does not have to come from the sleep doc.
I have a better relationship with my GP than the sleep doc just because my GP has known me for over 20 years and he trusts my judgements as I trust his.

So good luck getting the insurance to cover your APAP. I use one every night and I know it has improved my therapy over the years.

Karen

[RipVW]

Yes, just get any doc to write the script! Good luck!

[Wulfman]

A while back i purchased my own APAP machine after some discussions about my high AHI with my sleep doctor. I basically had to persuade him to write an Rx and I had to state that i did not want to return my existing CPAP to his (part owned) DME. Since having my APAP my AHI has dropped to about an average of 3 and my AI is mostly zero
Normally my insurance will cover a new machine every 3 years but it has been less that one year so i did not bother with a claim. However i have since found out from someone in human resources that insurance will cover the cost of the APAP if the sleep doc writes a letter saying it was medically neccesssary.

You guessed it, sleep doc does not want to write me the letter, he has a problem with it and will not say what.

So I'm wondering what he may have a problem with? Any ideas?

Ya lost me somewhere in that story, Bob.

What machine(s) do you have?

Do you already have a CPAP AND an APAP?

Do you have your prescription (physical document)? (what does it say?)

You can purchase an APAP with a CPAP prescription from CPAP.COM.


Den

[sleepycarol]

Did you talk to the insurance company or just the human resource person where you are employed? Did they know that you had a cpap that was less than a year old?

If your sleep doc has a vested interest in the DME you are probably out of luck. Did you buy your APAP from a DME or on-line? Will your insurance reimburse on-line purchases?

[rested gal]

I will follow up if and when I decide to see him personally although i doubt he will change his mind. Up until now i've been dealing through the medical assistant. He stated that he was against APAP right from the start.

Your doctor's ego may be a big part of what I think you correctly figure is going to happen if you have a personal conversation with him, no matter how polite and deferential you are.

He was very reluctant to give you an APAP Rx. I don't think he's going to like to hear that you were right and he was wrong about whether an APAP could treat you well. I suspect he especially won't like hearing that you've been getting better results through adjusting your own APAP than you were with his prescribed CPAP pressure.

Some doctors would be VERY pleased that a patient was proactive, intelligent; and, that through study and judicious tweaking was improving his/her own therapy. That kind of good doctor would probably also be interested in your data. I'd be VERY surprised if your doctor is one of those, however.

As for changing doctor i'm beginning to feel that i already have. I feel I have become my own doctor.

And you're doing a darn good job at being your own doctor now.

Quite a few doctors are not fans of autotitrating machines, even if "dollars" are not involved. Some have been influenced by the first studies that came out about autopaps not doing that good a job. Autopaps have changed a great deal since the first ones were introduced. But some doctors shut their minds to "autopap" back then and are not interested in keeping up with how autopaps work today.

Some anti-autopap doctors have been unfortunately influenced by more recent "autopap comparison" studies that use an artificial breathing machine to toss recorded waveforms of sleep disordered breathing at the autopaps. The widely varying performance between brands in those studies could make some doctors think the inconsistent responses between brands means autopaps in general are not "there" yet, so not worth prescribing. Artificial breathing machine studies leave out the absolutely critical factor autopaps need to "see" to show how each brand would actually treat a living breathing...those studies leave out feedback from a living, breathing person in the loop. So, "results" from those studies are not a good indication at all about how the various autopaps would treat live patients.

Jan 15, 2007 subject: An APAP Shootout (sort of) on Academic Journal (topic started by SamCurt)
viewtopic.php?t=16570
Within that topic:
viewtopic.php?p=140004#p140004 (my post criticizing the "artificial breathing machine" APAP comparisons.)
viewtopic.php?p=140063#p140063 (-SWS talks about "broken patient feedback loop.")

Finally, many doctors who try autopaps with some of their patients order the machine set 4 - 20. At that low a minimum pressure, it can take too long for the machine to move up to pressures needed to prevent apneas/hypopneas for most people. Too many events (apneas/hypopneas) can happen at the lower pressures. That need not have been the case if the minimum pressure had been set at a more reasonable (higher) pressure in the first place. But the doctors look at the AHI, see that a lot of apneas happened and conclude it's "autopap" in general that doesn't do a good job. Doesn't occur to them that it might have been the minimum pressure they prescribed that was the problem. They're going by what the manufacturer recomments -- set it for 4 - 20 and let it do its thing. Not the best way to use an autopap for ongoing treatment purposes.

Anyyyywayyyy -- looks like you're already doing fine handling your treatment yourself, Bob! With an autopap, of all things! Imagine that!

[kteague]

Ditto to what's already been said. Are you wanting the doctor to write a letter so that you can receive retroactive reimbursement of the machine you purchased or to get another machine? To prove medical necessity you'd likely have to "fail" cpap. I don't know how long you tried or what documented efforts were made, or what degree of success (or lack thereof) you had on cpap. Seems that would have to be part of the presentation if there were any hope of getting this thru as a medical necessity.

[mckooi]

Hi,

You sleep doc is following the money lines.....sleep doc only can give advices that's all.
Ultimately......the Auto Pap machine (the auto-pap have the function as Cpap as well just puch the butto to change) "ultimately" is the one doing the job "not the sleep doc"....so learn how to manage both auto-pap and apnea therapy.

These are the keys....DO NOT be afraid or uncomfortable to fire the sleep doc or dme......learn both the auto-pap and therapy are the keys to success.....also learn to fire....I bet you if someone get a stroke or accident the doc would say "oh.....is too late.....you should come to see me (pay $$$$) then what? just us the cpap machine.

Am not against sleep docs.....but mostly these are the trends that is what is going on in the sleep apnea medical industry.

"Learn and treat yourself is the key to success....come back to ask and share and gain wisdom"

Best Regards,
Mckooi

[jnk]

Unfortunately, you may not get the reimbursement; but I gotta say that I give you extra credit for sheer style, Uncle Bob.

If you feel that using the APAP made all the difference for you, and you can make your case with numbers, dates, and arguments to that effect on paper, you could always use a copy of the doctor's prescription as proof of medical necessity if he used the word APAP on his prescription. After all, why would he write the prescription if it wasn't necessary? Seems to me that the fact that he wrote a prescription specifically for APAP, if he did, ought to be proof enough, if I understand your story properly.

Either way, if I were you, I would put the document with your scientific proof together and submit it to your doctor for another signature from him. Even if he refuses to sign, I would send it to my insurance anyway, just for the principle of the thing. It might be worth it just to get your argument on paper for the education of the doc and the insurance people, if you think you would get any satisfaction out of doing it, whether you get the reimbursement or not. If you do it respectfully and logically, they will at least be on their toes in knowing they are dealing with a serious player.

Kudos to you, Uncle Bob.

jeff

[el_zorro]

Doctors dont always know everything and may not consider many factors. I just finished two weeks of travel including some high-altitude stuff and international travel to China and found that my pressure varied quite a bit and APAP came in real handy. After tweaking EPR/max/min I was able to get my AHI consistently below 5 on the road with ultra-low humidity, jet-lag, a drink or two, altitude, and pollution causing sinus problems. At home I am fine on straight CPAP since my sleep lab did a good job with my titration but for a travel machine I am sure glad I got an APAP.

Read through the forums and gather as many good reasons to bring back in front of your doctor. Its pretty clear than getting a kick-back from the sleep lab for a re-titration every couple of years is a good reason why they dont like APAP.

[josef]

My sleep Doctor thought I didn't need an APAP Machine either. As you can see below, just about anyone can write the prescription for the machine. The link will take you to CPAP.COM frequently asked questions) where you can even find a prescription form. I requested a prescription from CPAP.Com, entered my PCP Doctors name. (not the sleep Doctors) They contacked him, he filled out their prescription which has many detailed boxes and faxed it to them. I then simply downloaded a copy of this prescription from CPAP.Com and used it on CPAPauction.com where I bought a very nice REmstar auto m with aflex with low hours for $250.00 complete with humidifier, travel bag and hose. This same prescription has all the other medically necessary supplies filled out which allows me to buy masks or anything to my hearts contents. I haven't done this yet, but I intend to take a blank form to my Dentist and see if he would sign it and I have 3 sister in laws who are nurse practioners, I'm going to ask them also. I have Encore Viewer, Encore pro 1.8 and also encore 2.2 if you or anyone needs it. I can help you get them for free. I have a bad feeling though that I will spend my dying days locked up in prison for foiling the best efforts of the sleep industry to keep us patients in the dark ages.


https://www.cpap.com/cpap-faq/Prescriptions.html#366

Who can write a Prescription?
The prescription can be written by any of the following care providers:

•Medical Doctor
•Physicians Assistant
•Nurse Practitioners
•Doctor or Osteopathy
•Dentist