Insurance Denial

sleepyteacher · Post by **sleepyteacher** » Sat Jun 29, 2019 2:19 pm

I am frustrated....

My primary physician and ear nose throat doctor said I needed a home sleep study.
Insurance complied and I was given a home sleep study; results showed I stopped breathing 47 times in a hour.
I returned to ENT; he writes an order for a clinical sleep study. Necessary, so the techs can set the right pressure for the CPAP machine.
I get call for insurance company telling me I will not get 2nd study but I will get machine; an APAP.
I even had a document sent to me stating this information sent by snail mail.
Month goes by, I call about equipment....Rep. from insurance company says company cannot send machine; b/c they do not know what
to set the pressure at.
Hmmm? I ask "How do you get that information; about pressure and settings?"
Rep. replied "From a clinical sleep test."
AND AROUND AND AROUND WE GO...…….
Round 2: My ENT has to speak with the Insurance DR. about getting me a clinical sleep test.
Meanwhile I am getting written up at work b/c I am falling asleep on the job.

Pugsy · Post by **Pugsy** » Sat Jun 29, 2019 2:23 pm

Welcome to the forum.

Typically when people are given the apap auto adjusting machine instead of having an in lab titration sleep study the settings are just the default from the factory settings....minimum pressure 4 cm and maximum 20 and after a few days the software reports are looked at and then more appropriate settings are dialed in.

Tell you doctor to just write 4 cm minimum and 20 cm maximum so you can get the machine and get started with therapy.
Gotta start somewhere and 4 cm is where they would start if you were in a lab setting.

Bednbones · Post by **Bednbones** » Sat Jun 29, 2019 9:37 pm

Ugh- I feel for you. I know when I first realized I wasn’t breathing well and had a brother with sleep apnea (heart failure 1x and then a faint from standing up at night- hit head and had a few brain bleeds) - how important breathing and sleeping are, I wanted my machine that day.

My insurance wouldn’t pay for my sleep study or the machine. Annoying but one trip to a hospital would have been way worse.

Anyway- hope you get it straightened ASAP!

D.H. · Post by **D.H.** » Sat Jun 29, 2019 11:15 pm

To the OP:

If you were written up for falling asleep on the job, you rights under the ADA might have been violated!

TropicalDiver · Post by **TropicalDiver** » Sat Jun 29, 2019 11:49 pm

You have already gotten very good advice. This is how I would proceed (all at the same time):

a) Do as Pugsy suggests. Ideally, this should get you started on a machine and/or study.
b) If they will not do that, have them request approval for a titration study from your insurance. My personal guess is the insurance is essentially saying we don't need to do another sleep study as we already approved the device.
c) I would speak to the insurance and explain your problem -- you have gotten a study and a diagnosis but they need to do titration work to set up a script. What should they be requesting? Ask your doctor to do the same with the insurance.
d) Contact an attorney and/or you union. You have a disability that you are trying to address -- whether you disclose that to your employer is worth thinking through with counsel. Employer obligations don't really kick in (IIRC) until the have some notice of the issue.

Please make sure the machine you get is auto and full data. Others can/will suggest models (ResMed Airsense 10 AutoSet For Her or a Aircurve 10 VAuto would be my suggestions) -- I would ask the doc to write for the model you think is best.

Janknitz · Post by **Janknitz** » Mon Jul 01, 2019 2:23 pm

TropicalDiver wrote: ↑
Sat Jun 29, 2019 11:49 pm
You have already gotten very good advice. This is how I would proceed (all at the same time):

a) Do as Pugsy suggests. Ideally, this should get you started on a machine and/or study.
b) If they will not do that, have them request approval for a titration study from your insurance. My personal guess is the insurance is essentially saying we don't need to do another sleep study as we already approved the device.
c) I would speak to the insurance and explain your problem -- you have gotten a study and a diagnosis but they need to do titration work to set up a script. What should they be requesting? Ask your doctor to do the same with the insurance.
d) Contact an attorney and/or you union. You have a disability that you are trying to address -- whether you disclose that to your employer is worth thinking through with counsel. Employer obligations don't really kick in (IIRC) until the have some notice of the issue.

Please make sure the machine you get is auto and full data. Others can/will suggest models (ResMed Airsense 10 AutoSet For Her or a Aircurve 10 VAuto would be my suggestions) -- I would ask the doc to write for the model you think is best.

Mostly good advice but there is NO WAY this individual will be covered for an Aircurve 10 VAuto. That's a bilevel machine and you have to have documentation of medical need for this more complicated machine--OP doesn't have that documentation without a titration. The ResMed Airsense 10 Autoset or Resmed Airsense Autoset for Her (better) are both good machines to titrate at home and excellent machines to treat your apnea.

Titration at home makes a lot of sense. An in-lab titration is done under very artificial circumstances, and as it takes place only on one night it's a snapshot. But if you titrate at home under your usual sleeping conditions over several nights or even weeks, you get a good picture of what you really need pressure-wise, you have a chance to get used to sleeping with CPAP, etc. So IMHO the easiest approach here is to ask your doctor to write a script for the home titration with an APAP with the pressure set 4 to 20 cm/H2O to begin with and then adjusted as indicated.

ChicagoGranny · Post by **ChicagoGranny** » Mon Jul 01, 2019 2:40 pm

sleepyteacher wrote: ↑
Sat Jun 29, 2019 2:19 pm
Necessary, so the techs can set the right pressure for the CPAP machine.

With help from the forum, you can titrate yourself at home and do a better job than the sleep lab. Many of us have done this.

Insurance Denial

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Machine	Mask

Additional Comments: Auto PAP; 13.5 cmH2O min - 20 cmH2O max