insurance won't pay for titration

Hubs was diagnosed using an in home study with severe apnea We got his report, it said it was probably obstructive. The sleep center recommended he come in for a machine and titration. Our insurance won't cover the titration - so the center says insurance is providing him with an Airsense 10 which the center says doesn't need titration - it adjusts to what you need automatically. I've read the reviews on cpap.com and I've read what people on here say about that machine and it seems like it's a good machine but is it true he doesn't need titration? The center we are using says insurances are moving away from paying for overnights.
We don't have a "sleep doctor", I knew he was not breathing right and we went to our GP and got the home study. Our GP knows Nothing about apnea.
His physical health is otherwise fine.

Thanks,
J & V

Ingjv wrote:is it true he doesn't need titration

Many of us had to titrate ourselves at home and this is the best way for optimum results if you have a simple case of obstructive sleep apnea and no other significant health problems. Use expert opinions of forum members to optimize your therapy.

Ingjv wrote:severe (probably obstructive) apnea

You should remove "probably" from the equation. Ask for a copy of your sleep study summary. It's your right.

You can titrate yourself with an Apap, but it must be one that gives data (and the Airsense 10 does). When he gets the machine, he and/or you should download free software (SleepyHead) from here so you can see what's going on overnight and tweak machine pressures for adequate therapy. The machine will most likely (if it's new) come with a low pressure setting of 4 (machine's default low) and a high of 20, but 4 is actually too low for anyone to comfortably breathe at (the low setting is the more important one) so most who have not had machines set to some prescribed higher pressure will set the machine for a low of e.g. 7 for a week, use the software and see what it says, how they feel, etc... and go from there.

I also suggest he not bother trying the ramp feature as it's really more like using tricycle training wheels for people who've been prescribed much higher pressures (more than 10-15), and for someone starting out at 7 or so, all that would happen is that he'd get less than that pressure (therapy) for however long he set the ramp timer for, and the minimal sensation of 'air' being pumped (slightly) in at first is usually gotten over very quickly.

The Airsense 10 comes in four different models. Your hubby needs either an Autoset or Autoset For Her.
Men can use the "for her" model, as it has additional features anyone might use.
Do not let them sell you a "CPAP", as that one will not adjust or give detailed information.
The Elite gives full data, but will not adjust pressure, making home titration difficult.

Ingjv wrote:but is it true he doesn't need titration?

the machine does what in effect is a continuous titration, instead of relying on a few hours in a foreign environment where hubs likely won't sleep the same as he does at home.

as julie says, it's important to get the software, sleepyhead, and tune the machine after a few nights, so that it works better.

it'll work set to factory defaults, but it'll work better with some tuning.

think of it like driving on the freeway. if you pull up to the end of the onramp and want to merge with traffic, you've gotta wait longer for a bigger opening, and then floor it, and try to get up to speed before someone runs you over, or swerves to miss you.... that's like using the machine at factory defaults.

a better, more experienced driver will use the onramp to get up to close to highway speeds and then smoothly move into the flow of traffic with only a little extra speed increase, that's like using the machine tuned to his needs... it's already mostly where he needs it, and it easily picks up the little extra pressure to adapt to his changing needs during the night.

we'll help.

PailRider wrote: if you pull up to the end of the onramp and want to merge with traffic, you've gotta wait longer for a bigger opening, and then floor it, and try to get up to speed before someone runs you over, or swerves to miss you.... that's like using the machine at factory defaults.

You never were good at analogies, were you?

Ingjv wrote:Hubs was diagnose using an in home study with severe (probably obstructive) apnea. The sleep center recommended he come in for a machine and titration. Our insurance won't cover the titration - so they center says insurance is providing him with an airsense 10 which the center says doesn't need titration - it adjusts to what you need automatically. I've read the reviews on cpap.com and I've read what people on here say about that machine and it seems like it's a good machine but is it true he doesn't need titration? The center we are using says insurances are moving away from paying for overnights.
Thanks,
J & V

If your husband has pulmonary or heart issues, yes, you should push the insurance company to cover an in-house titration. If not, then going with one of the top-of-the-line cpaps is perfectly fine. You can produce reports yourself or provide the SD card from the machine for his doctor to determine best settings.

Kaiser routinely does home studies and home titrations. There are peer reviewed articles out there showing that home titrations are just as effective as in lab titrations. Personally, I agree. In a lab all you get is a "snapshot" of one night under very artificial conditions--strange bed and environment, sleep quality may be poor under those conditions. With an in home titration, you get a week of sleep in your own bed and sleeping conditions. Seems to me that's much more accurate.

In some cases an in lab titration can be helpful--good staff could help fit the mask and talk someone through the process of learning to sleep with the mask. But often you don't get that, and they cost a LOT of money!

Try the home titration first, and INSIST that your husband get a data capable machine afterward. If he is not doing well after a reasonable attempt, then an in lab titration may be indicated.

First, get the name of the insurance representative that you are dealing with. Tell him that you need his/her name for failing in fudicary in coverage. Then, ask to speak to a supervisor.

Explain to the customer rep, there is a reason that all this equipment is Class II FDA medical devices that require an Rx. The first sleep test just determined that you had sleep apnea. Now further assessment is needed to determine the proper devices and settings. Do you need a CPAP, BiPAP, or ASV PAP? What settings. Do you require a nasal, full face, hybrid, or total face mask. Improper setting and equipment can turn a simple OSA into Central Apnea.

Let the customer rep know that if the refusal to give you proper medical care results in adverse health issues, you will sue the insurance company and the rep personally. If you still get no action, report the rep to the insurance board.

DxRxTx wrote:First, get the name of the insurance representative that you are dealing with. Tell him that you need his/her name for failing in fudicary in coverage. Then, ask to speak to a supervisor.

Explain to the customer rep, there is a reason that all this equipment is Class II FDA medical devices that require an Rx. The first sleep test just determined that you had sleep apnea. Now further assessment is needed to determine the proper devices and settings. Do you need a CPAP, BiPAP, or ASV PAP? What settings. Do you require a nasal, full face, hybrid, or total face mask. Improper setting and equipment can turn a simple OSA into Central Apnea.

Let the customer rep know that if the refusal to give you proper medical care results in adverse health issues, you will sue the insurance company and the rep personally. If you still get no action, report the rep to the insurance board.

Surely you jest.

DxRxTx wrote:a lot of worthless, expensive tripe deleted.

really... such garbage.

DxRxTx wrote:First, get the name of the insurance representative that you are dealing with. Tell him that you need his/her name for failing in fudicary in coverage. Then, ask to speak to a supervisor.

Explain to the customer rep, there is a reason that all this equipment is Class II FDA medical devices that require an Rx. The first sleep test just determined that you had sleep apnea. Now further assessment is needed to determine the proper devices and settings. Do you need a CPAP, BiPAP, or ASV PAP? What settings. Do you require a nasal, full face, hybrid, or total face mask. Improper setting and equipment can turn a simple OSA into Central Apnea.

Let the customer rep know that if the refusal to give you proper medical care results in adverse health issues, you will sue the insurance company and the rep personally. If you still get no action, report the rep to the insurance board.

Good luck with that. Home titrations are considered acceptable and reimbursable by Medicare. Rant and rave all you want if you enjoy beating your head against a brick wall.

Now, if you do your home titration and you are STILL having issues which are not resolved by the machine and settings determined in the titration, then you have a case for getting an in lab titration. But just because you think it will be better is not a reason your insurer has to comply.

How would you find out in a home- test about the sleep architecture (REMs for example)?
What's the name of the insurer that would not pay for titration?

I had a friend who had to fight with his insurance company to pay for the anesthetics associated with a colonoscopy. The insurance initially would only pay for the colonoscopy. I have Kaiser Permanete insurance because I don't have to fight. The rules and copay are very clear as to what is and is not covered.

Janknitz wrote:Rant and rave all you want if you enjoy beating your head against a brick wall.

+1