Hopefullady wrote:Just spoke with doc. He says Medicare will not pay for me to have a device because this wasn't high enough, even with comorbidity factors (heart problems).
Mild sleep disordered breathing with AHI 4% of 2.9. Using
alternative criteria, mild sleep disordered breathing with AHI 3%
was 19 events per hour. No hypoxemia.
I know I'm a bit late to the game, but this caught my eyes.
There are
two distinct ways of scoring a hypopnea on an in-lab sleep test. The AASM Recommended Standard and the AASM Alternative Standard for hypopneas. See
http://www.ncbi.nlm.nih.gov/pubmed/19238801 and
http://www.journalsleep.org/ViewAbstract.aspx?pid=27368 for a scholarly discussion of how and when these two standards affect a patient's diagnosis of OSA as well as the formal definitions of the two standards:
- AASM Recommended Standard (Rule 4A): A hypopnea requires at least a 30% reduction in airflow for at least 10 seconds AND a corresponding O2 desaturation of at least 4%. Such a hypopnea does NOT require an EEG arousal.
- AASM Alternative Standard (Rule 4B): A hypopnea requires at least a 50% reduction in airflow for at least 10 seconds AND one or both of the following conditions: A EEG arousal OR a corresponding O2 desaturation of at least 3%.
The reason there are two standards for scoring hypopneas is complicated and I have to admit I don't understand it all. But basically Rule 4B was accepted as a legitimate standard for scoring hypopneas because studies have indicated that the arousals from Rule 4B hypopneas are just as serious as the O2 desats from Rule 4A hypopneas. In other words, the sleep docs seem to think both kinds of hypopneas are important when it comes to determining the quality of the patient's sleep. But Medicare has balked at the idea of counting anything but Rule 4A hypopneas, and Medicare is a huge part of the sleep medicine market. I also think that there is an expectation that for most people with OSA, it doesn't really matter all that much which standard is used: If most of your apneas come with a 50% reduction in airflow AND a 4% drop in O2, they're going to be scored under both criteria. But for a small number of patients, the difference in the hypopnea definitions
does matter. And you appear to be one of those patients. I am another one of those patients.
It appears from the way your test results were written that the lab you had your sleep test at scores
both kinds of hypopneas, but they split them into separate categories and report separate AHI's for the two scoring methods.
Under the Recommended Standard, the hypopneas are required to have a 4% O2 desat to be scored, and it appears that under this definition your AHI was only 2.9, which is well under the magic threshold of 5.0 for mild OSA.
But under the Alternative Standard, the hypopneas are NOT required to have an O2 destat at all if there is an EEG arousal associated with the hypopnea. And your AHI under the Alternative Standard is 19, which indicates that many or most of your hypopneas scored under Rule 4B were "hypopneas with arousal" and involved little or no O2 desaturation. And that Alternative Standard AHI = 19 technically puts you into the
moderate OSA range---for a doc who uses the alternative standard. I point this out because my initial sleep test results were similar to yours: Under Rule 4A, my AHI was only 3.9, but under Rule 4B, my AHI was 23.8. And my doc diagnosed me with
moderate OSA and was extremely insistent that I must be put on PAP and I must be put on PAP NOW.
The thing is:
I was NOT on Medicare; I was on my employer-provided health insurance and my health insurance didn't care which rule was used to score my sleep test. You are on Medicare and Medicare only recognizes Rule 4A as "legitimate", even though the literature in sleep medicine indicates that the arousals from Rule 4B hypopneas can be as disruptive and detrimental as the Rule 4A hypopneas.. My guess is that if you were NOT on Medicare, the doc would be happy to prescribe a PAP for you and your employer provided health insurance would be happy to pay for the machine.
Back when I was sorting out the meaning of my own sleep test data I finally asked the PA treating me out right:
If I were covered under Medicare, would they have paid for my machine? The PA answered, "No, not without winning an appeal based on medical necessity. But Dr.
X would have pushed for appealing a decision to not cover your machine."
I bring this up because it seems to me that since you have other co-morbidities, it would be reasonable to ask your sleep doc to file the necessary paperwork with Medicare asking for a wavier of the Rule 4A scoring of hypopneas in favor of scoring them under Rule 4B in your case. It may not get you anywhere. But if the co-morbidities are serious and you are living with symptoms of OSA, it's worth appealing a denial of coverage that is based solely on the fact that the Rule 4B hypopneas are "not counted" in your Medicare AHI.