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[Equipment] Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
#11
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
Thank you again for the kind support. I have tried chin straps, hose support, etc. but have not tried mouth taping. I have not tried a neck collar. I am of course happy try to these regardless of the surgical path. Espeically if they improve things in the short term. 

I realize now that I gave you guys a screenshot over an hour long. I'm sorry I misread it the graph; I was a little tired (surprise) when I made it. 

Here is an updated one focused on an event.


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#12
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
The signs of flow limitation are clear. The part of the flow rate trace above the zero line represents your inhalation. It should have a nice curve at the top. Instead, breaths (ignoring the recovery breathing after the OA) mostly show dented or pointed tops that are characteristic of flow limited breathing. The machine's algorithm captures only some of this.

Flow limitations generally represent some relaxation of the tissues lining the airway. The reason they may be important is that when your flow is limited, you have to work a little bit extra with each breath to complete your inhalation. Adding the effort up over night means you're working pretty hard. At least as important, these efforts may be preventing you from having normal sleep cycles, by making deep sleep and REM sleep hard to achieve or by disrupting sleep with frequent mini-arousals.

I suspect the advice you'll get is to increase your EPR to 3 to see whether this helps with the FLs.

I had a lot of FLs, even at EPR of 3, and eventually (on the advice of Bonjour and Sleeprider here) got my hands on a lightly used VAuto Aircurve bilevel machine, which allows EPR greater than 3. (It's called pressure support on this kind of machine.) This greatly improved my FLs and made a real difference to how I feel during the day.

Even if you've tried other straps, you might take a look at the Knightbridge. And I hope a collar and/or tape will help you as well. As an earlier post made clear, large leaks can be quite disruptive to sleep, whether you recognize it during the night or not.
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#13
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
Where can I find more research to better understand flow and flow limit? I want to make sure that I am not speaking from opinion when I speak to my doc. 

I really want my sleep doctor to correctly describe this in my chart, instead of saying my "leaks are normal." They clearly are not, but whatever their software is they use to interpret leaks is very high level / summarized and they only take a VERY cursory look when reviewing. 


I have never had anyone in healthcare ever analyze my data at this level of detail. Where can I learn more? Without disclosing your name or anything, do you have a background/clinical/technical experience that helps you understand sleep data? 

Thanks again for your kind advice.
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#14
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
Here is some more information about flow limitations:

http://www.apneaboard.com/wiki/index.php...limitation

The wiki is a good source of information about lots of things.

I don't have any professional training in this area, though I suspect some of the other members do. At any rate, if it's possible, I'd recommend showing your doctor your charts. No one could look at those at say your leak levels are fine.

I also really hope your doctor will support you in making some changes to your pressure settings, as has as been suggested. For what it's worth, I'm skeptical that your insurance company would know or care if you changed your settings. Any way you can confirm or disconfirm that impression?
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#15
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
I will definitely be sharing my OSCAR data with the doc. I have already shared my myair graph in an email posing the question as to why they are writing that my leaks are "normal." 

I have made adjustments to my pressure in the past and the doc has been relatively supportive. I have gone from 15-16 cm down to 11 and 12, and now recently back up to 14. I've also done two rounds of APAP on two different devices. Unfortunately, because of the amount of scrutiny and detail with which the insurance company is reviewing my medical records, I feel like it is necessary to be careful. The doctors who approve or deny care are motivated by bonuses and financial targets, and I get it, but they're in a position to use any reason necessary to prevent me from pursuing care and staying locked into the CPAP paradigm. I'm pretty sure they aren't even sleep doctors. I'm pretty sure they see AHI and look at one or two variables, and do not consider total health. 

I would be fine with using CPAP after a surgical intervention, if going from severe to mild meant i could tolerate a lower pressure. However, the research - large meta analyses - shows that there is a good chance of cure or reduction from severe to mild. And in my case, I can see the retrognathy and therefore understand why this deformity contributes to my apnea. Going from severe to mild or cure <5 AHI without CPAP could really aid my weight loss (already down almost 60 lbs) and significantly improve my QOL. 

I mentioned earlier in this thread that they tried to say I "use marijuana" in a denial record. Not only is this untrue, it being part of the record now is in the way of the surgical course of action im currently pursuing. This is why I'm being fairly conservative and want my doctor's buy in on changes to CPAP. I've tried APAP before. Mouth taping, knightsbridge jaw strap, and a few other suggestions seem logical, and Im wiling to put them all on the list and try. I feel that, at this point, I am clinically intolerant of CPAP at these pressures and the side effects after two nasal surgeries have caused me to go into anxiety and phobia territory. I am compliant, but intolerant - and Im committed to exhausting all ideas before just giving up on CPAP - which carries risks I know are very serious and I do not want to mess with. I have encouraged tons over many years on many forums and in person to stick with CPAP. But I am getting to the point where I feel like I'm part of a group of people for whom this treatment just isn't working - and research on residual somnolence seems to speak to my situation. 

I've attached bcbs policy for MMA interventions in case it is helpful to anyone else. I am discouraged but remain hopeful (and thankful for all of the judgment free advice.)


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#16
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
Thanks for posting the policy statement. I'll be curious how your appointment with the sleep doctor goes; if you have a chance, would you keep us posted?

Meanwhile, congratulations on the weight loss. That's hard, and I'm impressed!
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#17
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
@bonjour, @sleeprider, @dormeo

Thank you for your kind advice. Got some good news, insurance company approved my surgery.

in the meantime, im going to see about trying the APAP again. i feel like the sleep doc will support me.
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#18
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
I'm glad your doctor and insurance company are supportive of your plan. When will you have the surgery?
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#19
RE: Trying to get insurance appvl for MMA surgery, sleep doctor saying my leaks "normal"
The ortho is doing some pre work to make sure teeth line up in the post op bite. Surgery will be scheduled after orthodontics, at some point in the Spring. Maybe March or April. 

My focus now is: 

diet & exercise -> more weight loss
tweaking cpap or APAP with sleep doc
researching mouth leaks, chin strap, taping, etc.
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