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Apnea's Adventures in Insurance Wonderland
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Mark Douglas Offline

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Posts: 513
Joined: Apr 2015

Machine: Sys 1 (60) RemStar BiPAP Auto with Bi-Flex 760P Auto Bi-Level (Variabl
Mask Type: Nasal mask
Mask Make & Model: PR Wisp
Humidifier: PR Sys One heated
CPAP Pressure: RiseTime 3 Fxd E-9.0 / I-11.5
CPAP Software: SleepyHead EncoreBasic

Other Comments: Hashimoto's thyroiditis.

Sex: Male
Location: SW Ohio

Post: #1
Apnea's Adventures in Insurance Wonderland
If anyone is interested I will log my experiences here of trying to get CPAP therapy the traditional way. This is to be my attempt at a more coherent account following on my previous threads Rolleyes

A little back round as to why this has suddenly become critical to me. I have had one health problem after another since early adulthood. I seldom awake feeling refreshed even in my youth. I have been prescribed sinus surgery due to repeated sinus infections. Hashimoto's disease. Treatment for GERD. Psychiatric care and meds for depression. And on and on..... I recently remembered (quite clearly) being tested for narcolepsy in my early twenties. Of late with the help of this board it now seems ALL my problems can be related to OSA. I am not crazy. I AM sick and tired of being sick and tired! A couple of months ago after resisting for some years I accepted treatment for ADD/HD in the form of amphetamines. Was a miracle. I was better focused. Hopped out of bed ready to go. Then I collapsed. My best explanation is I was getting say 4 hrs of sleep but was now burning 8 hours of sleep energy and finally any reserves were used up and so I collapsed. I think it was retired guy who mentioned sleeping in a comfortable chair instaed of bed so wife bought me a superduper Lazyboy XR+ chair and I am doing better in it. Her too with me out of the BR Laugh-a-lot

About three weeks prior to today I scheduled a preliminary visit with a sleep doctor a short drive from my home. This is scheduled for May 5, 2015. At the time that seemed way too long to wait.

Tuesday April 21, 2015:
My wife and I had a joint appointment with our GP Doc and at it's conclusion we were both diagnosed with code 327.23, Obstructive sleep apnea. I expressed my concern about what I read concerning the Alice in Wonderland like insanity that seems quite commonly experienced by others. Doc says he will order the sleep study and receive the results and he will be writing the Rx for treatment plan including a CPAP machine as appropriate. We leave with printed orders for sleep studies at local mega hospital and we drive to said hospital to book these studies in person ASAP.
Now it begins. I explain GP says to schedule study and here is printed order for sleep study. Lady at the desk says no sleep study. She rcalls Docs order for sleep study as "referral". They require a first visit with one of their sleep doctors. To schedule study w/o preliminary visit would be a liability for the sleep docs. Then will need cert from Cigna to schedule study. Then return visit for consult after sleep study. If sleep apnea is diagnosis then Rx will go to DME to order equipment. How long will all this take? Scheduling appts for JULY. Maybe see equipment in August. I say no way I can wait that long. Offers they have new off-the-plane doc from India and he can see me May 4 if that is acceptable. This is one day prior to already scheduled appointment. So I have asked GP office to get me in again ASAP or for Doc to call me and discuss this. As I type this Doc calls me ............... and says to call other sleep centers to see if I can get in sooner. He doesn't need someone else to decide if I need a sleep study. He is not pleased....

I simply cannot wait all this time and I am not one to sheep-like put my faith and wallet in the hands of the medical mafia. At this point I am going to purchase a used auto machine by whatever opportunity presents itself out of pocket for as little cash as possible and with the help of SleepyHead have a go at self doctoring myself. I will also continue the path of Apnea's Adventures in Insurance Wonderland and see where that leads just so I know and what wife can expect.

I use my PAP machine nightly and I feel great!
Updated: Philips Respironics System One (60 Series)
RemStar BiPAP Auto with Bi-FlexModel 760P -
Rise Time x3 Fixed Bi-Level EPAP 9.0 IPAP 11.5 (cmH2O)
04-22-2015 11:49 AM
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Sleeprider Online
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Posts: 3,369
Joined: Dec 2014

Machine: Resmed Aircurve 10 Vauto
Mask Type: Nasal pillows
Mask Make & Model: Resmed Airfit P10
Humidifier: Resmed Climateline
CPAP Pressure: Auto Bilevel 18/9, PS 3
CPAP Software: ResScan SleepyHead EncoreBasic

Other Comments:

Sex: Male
Location: Where they make Respironics

Post: #2
RE: Apnea's Adventures in Insurance Wonderland
I think, the problem is the policy of the sleep center to put you under the care of one of their sleep specialists. When I had a study done, it was at the request (referral) of my primary care physician. The sleep center conducted the study and a specialist reviewed the results and made a recommendation to may PCP. That is what you're looking for, a sleep center to do a diagnostic or split diagnostic/titration study.

If you cannot obtain a sleep study without being subjected to another layer of doctors, then I would ask my personal doctor for a referral for a home study. This can be the fast-path to getting an auto-titrating CPAP prescribed. Basically, get the study approved (most insurance is all in on the idea of saving money), then use the diagnosis as the basis for prescribing an auto cpap, mask, supplies and accessories. Just do a search on home sleep study, and let your doctor help, or based on your doctor's existing referral, ask your insurance provider.

If you try to self treat, you will find many older, non-data machines. You are going to have to get educated in what Auto machines are good enough to do the job. Your doctor can prescribe masks and supplies, so you can get that from online providers. For that matter, your doctor could prescribe CPAP for you, and you can get your choice of new or used equipment from a provider in the Supplier List on the top of this forum. With modern APAP and data logging, there really is no need to get a sleep study other than to keep insurance happy. If you're going to pay out of pocket anyway, just get the prescription, and get good stuff, then review the data results with your doctor.

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04-22-2015 12:23 PM
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DariaVader Offline
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Joined: Nov 2014

Machine: Resmed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10 for Her
Humidifier: H5i humidifier with ClimateLine heated hose
CPAP Pressure: 8-15
CPAP Software: SleepyHead

Other Comments: diabetes II, Thyroidectomized, Primary Immune Deficiency, and the list goes on :P

Sex: Female
Location: Oregon

Post: #3
RE: Apnea's Adventures in Insurance Wonderland
Cigna prefers the home study anyway... I also have cigna

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
04-22-2015 12:35 PM
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justMongo Offline

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Posts: 3,853
Joined: Sep 2013

Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #4
RE: Apnea's Adventures in Insurance Wonderland
If the GP says you have OSA, he should write an Rx for an auto pap.
Of course, with your insurance, that's jumping the queue.

Your recourse is the have the GP write the Rx for an auto pap; and then pay out-of-pocket for a machine.
If he won't write the Rx, then he's not 100% sure you have OSA.

Most of the "long poles in the tent" are created by insurance companies who really don't want to pay out; just collect premiums.

My 2 cents.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
04-22-2015 01:14 PM
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Mark Douglas Offline

Advisory Members

Posts: 513
Joined: Apr 2015

Machine: Sys 1 (60) RemStar BiPAP Auto with Bi-Flex 760P Auto Bi-Level (Variabl
Mask Type: Nasal mask
Mask Make & Model: PR Wisp
Humidifier: PR Sys One heated
CPAP Pressure: RiseTime 3 Fxd E-9.0 / I-11.5
CPAP Software: SleepyHead EncoreBasic

Other Comments: Hashimoto's thyroiditis.

Sex: Male
Location: SW Ohio

Post: #5
RE: Apnea's Adventures in Insurance Wonderland
Yes we are looking at the home study for wife.

My purpose with this thread is to give new to this site/malady a first person account of one man's experiences, and perhaps one woman's, in the quest for treatment of this scourge as a tool for dealing with another's own situation. I will try to limit my comments to that end.

I use my PAP machine nightly and I feel great!
Updated: Philips Respironics System One (60 Series)
RemStar BiPAP Auto with Bi-FlexModel 760P -
Rise Time x3 Fixed Bi-Level EPAP 9.0 IPAP 11.5 (cmH2O)
04-22-2015 03:26 PM
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Mark Douglas Offline

Advisory Members

Posts: 513
Joined: Apr 2015

Machine: Sys 1 (60) RemStar BiPAP Auto with Bi-Flex 760P Auto Bi-Level (Variabl
Mask Type: Nasal mask
Mask Make & Model: PR Wisp
Humidifier: PR Sys One heated
CPAP Pressure: RiseTime 3 Fxd E-9.0 / I-11.5
CPAP Software: SleepyHead EncoreBasic

Other Comments: Hashimoto's thyroiditis.

Sex: Male
Location: SW Ohio

Post: #6
RE: Apnea's Adventures in Insurance Wonderland
April 22, 2015 1630 EDST.

Researched original sleep study facility and found out the WIC and contacted her directly and explained my plight. I now have an expedited appointment tomorrow April 23, 2015. Monster mega hospital appointment now canceled. Possibility was raised sleep doc may look over past split sleep studies and write an Rx for CPAP machine. One can hope!

Todays experiences reinforced my realization of years ago I am responsible for the quality of my health care. If I do not stand up for myself no one else will. Also advice from this board. Be polite but be firm. Squeaky wheel and grease don'tchaknow.

I use my PAP machine nightly and I feel great!
Updated: Philips Respironics System One (60 Series)
RemStar BiPAP Auto with Bi-FlexModel 760P -
Rise Time x3 Fixed Bi-Level EPAP 9.0 IPAP 11.5 (cmH2O)
04-22-2015 03:45 PM
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GrammaBear Offline

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Posts: 381
Joined: May 2012

Machine: ResMed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Air Fit P10
Humidifier: ResMed H5i heated humidifier
CPAP Pressure: 12.2 - 16.2
CPAP Software: SleepyHead

Other Comments: Type 1 diabetes - using Tandem T-slim insulin pump, Dexcom G4 CGM

Sex: Female
Location: northern Illinois

Post: #7
RE: Apnea's Adventures in Insurance Wonderland
Your 'saga' thus far is very interesting. I wish both you and your wife well and hope that things work out ok in the end.

Sadly there are other such stories as yours, although maybe none quite as accurately described as you've done.
04-22-2015 03:50 PM
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justMongo Offline

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Posts: 3,853
Joined: Sep 2013

Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #8
RE: Apnea's Adventures in Insurance Wonderland
(04-22-2015 03:45 PM)Mark Douglas Wrote:  April 22, 2015 1630 EDST.

Researched original sleep study facility and found out the WIC and contacted her directly and explained my plight. I now have an expedited appointment tomorrow April 23, 2015. Monster mega hospital appointment now canceled. Possibility was raised sleep doc may look over past split sleep studies and write an Rx for CPAP machine. One can hope!

Todays experiences reinforced my realization of years ago I am responsible for the quality of my health care. If I do not stand up for myself no one else will. Also advice from this board. Be polite but be firm. Squeaky wheel and grease don'tchaknow.
[Image: sthumb.gif] Eggzactly

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
04-22-2015 05:46 PM
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Mark Douglas Offline

Advisory Members

Posts: 513
Joined: Apr 2015

Machine: Sys 1 (60) RemStar BiPAP Auto with Bi-Flex 760P Auto Bi-Level (Variabl
Mask Type: Nasal mask
Mask Make & Model: PR Wisp
Humidifier: PR Sys One heated
CPAP Pressure: RiseTime 3 Fxd E-9.0 / I-11.5
CPAP Software: SleepyHead EncoreBasic

Other Comments: Hashimoto's thyroiditis.

Sex: Male
Location: SW Ohio

Post: #9
RE: Apnea's Adventures in Insurance Wonderland
April 23, 2015

Sleep Dr sees me at 1100 and listens to my story. Scans previous sleep studies and says he will send to his preferred DME order for a autocpap to be taken home in a couple days to use and after he gets results will write Rx for a new machine. Says he generally orders for an auto Resmd. FANTASTIC! Also says I have a really big uvula. In fact he looks twice like he cannot believe what he sees. Will research this later.

Wife works nearby so kill time until she can do lunch. She is most happy for me and lunch. Really happy I would be working with a small locally owned DME.
(is always funny to see reactions to Hard Hat Mark taking uptown financial district lady to lunch LOL )

1400 go to DME. This is the DME WIC who gave me name of WIC at sleep docs office who ultimately moved up my appointment by two weeks. First impression is not good. Guy who is at counter does not present himself well. I make it known I want to talk to WIC and am walked to her office. She looks up fax from sleep Dr and says uh oh you have Cigna and we are not in network. Oh crap ria . I explain I may just buy a machine and would she price that for me as a cash purchase. We talk and I ask a lot of questions. State I want a auto machine and leaning toward one that will run on 12vdc w/o converter or proprietary cord. She stares at me and says you are an engineer aren't you and you will mess with the settings won't you? ALL you engineers mess with the machines and then we have to fix them. And why do I want an auto anyway as they just cost a lot more..... ME ? says me in me best grin and voice of faux outrage. How would I know about clinician's menu anyway? I do admit to being a automation control specialist but not a EE..... l and OF COURSE I would never mess with their settings. .... Says she they send an auto machine out to learn my settings but probably won't need one after that. (so I get an auto machine for home titration and then a brick???)
She cracks a smile and says she will price for me and call me and they recommend Resmed and would have to be ordered. In that case please as a separate line item price the 12vdc power supply. At which point I get a blank look. Now I am really unimpressed BUT this IS the lady who made my expedited appointment possible and I believe in helping people who help me.
Horned by yet another dilemma. That makes two dilemmas today. Would like to reward sleep Dr for being reasonable but what is he gonna think and more to the point will he work with me if I buy own machine? I 'll get in touch with his WIC and see what she says.


April 23, 2015.

The enlarged uvula could definitely be a problem and from sleep Docs reaction almost certainly is. Why has no other dr. pointed this out? I want every advantage I can get in my pursuit of a good nights rest. Ans seems to be the ins co.s call this cosmetic surgery and so the docs don't even raise the subject. Get CPAP get healthy and strong then see about URS.

I use my PAP machine nightly and I feel great!
Updated: Philips Respironics System One (60 Series)
RemStar BiPAP Auto with Bi-FlexModel 760P -
Rise Time x3 Fixed Bi-Level EPAP 9.0 IPAP 11.5 (cmH2O)
04-24-2015 10:45 AM
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trailrider Offline

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Posts: 304
Joined: Feb 2015

Machine: A10 Autoset for Her
Mask Type: Nasal mask
Mask Make & Model: Eson or P10
Humidifier: autoset
CPAP Pressure: 6-12 DME, 7-13 me
CPAP Software: SleepyHead

Other Comments: engineer. EPR at 3, unheated hose, humidity at 2. Routine hose entanglement.

Sex: Female
Location: Ontario

Post: #10
RE: Apnea's Adventures in Insurance Wonderland
Interesting story Mark! But I thought the Resmeds need 24V...(I could be wrong, too lazy to go look). Well at least you will have a machine to get started and to get fitted for a comfortable mask.

Now the hard part comes in getting used to it. Best of luck for the next three weeks with that!
04-24-2015 01:14 PM
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