Odd Insurance Coverage Issue - Any Thoughts

[cmpman1974]

After the massive effort of having to move to another sleep medicine doc after my doc of 15 years dismissed me as a patient, it has been an endless struggle.  The new doc decided (without any verbal conversation yet) to move me from BPAP ST-A to BPAP-S .  Apparently the script wasn't even for a VAuto machine allowing auto-titration if wanted.  I don't understand why a doctor wouldn't want that option if costs were comparable and no insurance hurdles are existent. 

The big issue is the DME today told me insurance will NOT cover a lower less featured machine like a standard BPAP when I'm on a ST-A  I figured they'd be thrilled to pay less cost, but the DME said nope. She said you can only go up in features, not down as it's a once every 5 years thing.  I don't own the machine.  I'm in the middle of a 12 month rental period. The ST-A machine has BPAP-S mode, but not VAuto mode.  It also doesn't offer Easy Breathe like the VAuto and S machine do.  So after all this time, effort, expense of a new sleep study, I have achieved nothing. : Sad.  Never even got a copy of my sleep study results/report yet.  I think that's finally arriving in the mail today.  

There is no reason things should be so difficult.  I'm fed up.    The DME told me a ST-A machine can do all the VAuto does.   Then the person admitted she's not a respiratory therapist and not that educated on the machine details.

[Sleeprider]

Have you tried contacting insurance directly?

[cmpman1974]

Have you tried contacting insurance directly?

Not yet.  I was waiting to see the sleep study results which I finally got in the mail this afternoon.  These were from my April 2023 study at the new facility. I'm truly more lost than ever after reading this.  It showed w/o CPAP/BPAP, my AHI is 37 which doesn't surprise me (severe sleep apnea). 

The part that blows my mind is they claim I rarely go under 90% O2 even OFF treatment at night.  Supposedly in a 2 hr non-treatment portion, 0.4% of the time I was under 88% and I did sleep a decent amount.  HOW?  During titration, they said 0% under 88% at 17/9 BPAP pressure. So the doc I saw for 15 years wrote religiously about low O2 stats and pushed for different machines and testing, but this place identifies no O2 issues?    The report said I have 57 period limb movements per hour.  I imagine mostly due to major spine stiffness and terrible beds there.  AHI was 4.7 for the titrated portion at 17/9 for 67 minutes.  My total REM% for the entire night was a whopping 8%.  


My health has been about the same for the last 3-4 years.  No huge weight loss or changes to explain a complete elimination of O2 desaturation during sleep even on treatment.  Total titrated time was about 4.5 hours on various CPAP/BPAP pressure settings.  Hardly any CAs at all during the study.

7 drops per hour of 4%> SPO2 during the treatment portion. Crazily almost all desaturations happen on my side, not my back.  

I have included a copy of the pressure titration table.  IF this data is true, all of us can just toss our Wellue and Lookee O2 devices in the nearest garbage cans knowing they are useless. That would mean they are grossly inaccurate. 

Still lost as ever....

[Sleeprider]

I don't trust a DME's interpretation of insurance policy. Go straight to the source and find out the criteria for approval. I have seen members being treated on ASV that their DME said needed a sleep test for a new machine, and the test came back with an obstructive sleep apnea diagnosis and CPAP recommendation, in spite of more than 70% of apnea being central in the diagnostic portion of the test. The doctors, clinics and DMEs are incompetent, and you just have to realize that.

[cmpman1974]

I don't trust a DME's interpretation of insurance policy. Go straight to the source and find out the criteria for approval.  I have seen members being treated on ASV that their DME said needed a sleep test for a new machine, and the test came back with an obstructive sleep apnea diagnosis and CPAP recommendation, in spite of more than 70% of apnea being central in the diagnostic portion of the test.  The doctors, clinics and DMEs are incompetent, and you just have to realize that.

I am definitely doing that.  I just spoke with the DME respiratory therapist.  She said the same as me....the fact two sleep studies performed within 7 months of each other showed such drastic O2 results is insanity.  How do you go from 120+ min under 88% in Sep-22 to no minutes under 88% in Apr-23 both on 17/9 pressures BPAP-S?  First thing she asked me was why didn't any doctor do an overnight pulse-ox study while I was on BPAP-S at titrated pressure?  I said asked five different docs and all five didn't care enough to do it. 

This just borders on ridiculous.  I need some clarity on all of this!