Insurance Woes

Well, I'm now in limbo. My insurance company will not approve my cpap because I do not have sleep apnea! DUH! I have upper airway resistance syndrome! My doc never said I have sleep apnea! Just a little venting here!

My sleep study showed many micro-arousals which kept me from REM 3 or 4 sleep the entire study. My doc sent me home with an auto cpap for a trial and boy did it work - I even slept for 9 hours one night!

The company who will supply the cpap said they'd try to straighten it out, would call the insurance company and the doctor to get it fixed.

I'd say at least I don't snore, but my husband says I get very restless and therefore, he wakes up half the night and I am left so very tired. I also have restless leg syndrome which has stopped thanks to Klonopin and an extra iron supplement. So at least I'm not making an earthquake with my legs like I was!

Anyway - thanks for listening to my vent and I'll keep you updated. I have found so much information on this site - you all are more knowledgable than most doctors and insurance companies!

sleepyred:

Just have your DR diagnose you as having SLEEP APNEA as most of your description of events fit into the sleep apnea area. Have the doc also write you a scrip for the cpap machine and i beleive then everything will be covered by your insurance co. Tell your doctor to stop playing word games - if he's telling you to get a cpap then change the wording to (SLEEP APNEA) and put it down on the prescription-PERIOD!!!


best to you,

steve,
ufo13

Sleepyred,

I have also found, if your doctor won't comply with what Steve recommended, that if you ask him to write a letter of medical necessity to the insurance company stating why it is you need the therapy and equipment, they will review it and, in my experiences in most cases like this, can and will authorize it to go through.

There is no question you need the machine. CPAP therapy is also known to help alleviate RLS or PLMD. You may not need Clonazepam if you are on the machine. I had 14+ PLMs during my sleep study, as compared to only 4 hypops and 0 apnea per hour, and I don't need anything for the PLMD after being on the machine. So that in and of itself is a good reason, aside from airway resistence syndrome, to be put on it. Your doctor has to step up to the plate and either do what Steve said or write you that letter.

Stay calm until you hear you won't be given the machine. Then you have a choice to buy one yourself, which isn't really fair since you medically do need it, but at least you'll be getting the help you need. But a lot of times, an insurance company's denial is due to the code the doctor puts in on the form or his way of listing the ailment. He needs to rectify that or write you that letter. Either way, you should end up with it eventually.

ufo13 wrote:sleepyred:

Just have your DR diagnose you as having SLEEP APNEA as most of your description of events fit into the sleep apnea area. ...Tell your doctor to stop playing word games - if he's telling you to get a cpap then change the wording to (SLEEP APNEA) and put it down on the prescription-PERIOD!!!

Steve-

It would be nice if doctors could put whatever diagnosis they want so we would qualify for certain treatment, but medicine, and more importantly insurance, doesn't work that way. Most doctors don't make it practice to lie when they have an objective measure to determine diagnosis like sleep studies. More then likely the insurance company will want to see a copy of the sleep study results, and most doctors are not going to ask their techs, scorers and software programs to change their results to meet a certain diagnosis so even if the doctor changed the diagnosis to OSA the insurance would likely reject the claim based on lack of evidence. OSA and UARS may be on the same continuim to some degree, as is CSA- but each has its own diagnostic requirements and standard treatments that have been shown to work & are often FDA approved. At this point, xPAP has not been proven to be beneficial for people with UARS...they can't even decide on a definative definition of UARS, let alone standard treatment. Until it is proven to beneficial to treat UARS with xPAP, insurance will not be likely to pay for it without additional evidence that it is medically necessary on a case by case basis- which it sounds like the OPs doctor & DME are working to provide. If you look back 10 years ago, xPAP wasn't prescribed unless you had 10-15 or even more apneas and now it commonly is. Maybe if insurance companies see enough of a benefit they will start covering xPAPs for UARS at some point...if they never see anyone formally DXed with UARS because the diagnosis is changed to OSA they will never be able to find out if its worth while.

In the mean time, the insurance is not saying she cannot use a xPAP for treatment of UARS, just that it isn't a covered benefit according to her policy at this time, the same as they do with many medication that are not FDA approved to treat a specific disease, like Provigil. You can make a choice to pay for it yourself or wait for the insurance companies appeals process. It sounds like the doctor & DME are doing all they can, but in the mean time are the continuing to provide a machine? In my case it wasn't clear if BiPAP ST would be beneficial for my severe CSA since I still had 30+ centrals per hour with it, so my sleep doc and the DME affiliated with his office provided me with a BiPAP ST for free for the first month before we even involved the insurance company. Considering montly rental is $600+ for this type of xPAP and they knew I planned on using a different DME if it was approved, they definantly went above and beyond to make sure I could get the best care possible. That some doctor also has been very helpful any time my insurance won't pay for a particular med- currently its Lunesta and they have been mailing me samples to get through until we go through the appeal process.