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Rant about insurance, sleep study, and costs
#1
Rant about insurance, sleep study, and costs
I have been waiting on the Phillips recall to replace my System One 60 Series. Last year it didn't sound promising so I started the process to order a new machine instead.  I had my doctor write a script but the DME said I need an updated sleep study for insurance approval.  So the Dr. requested a home study.  The insurance denied it saying I needed a sleep center since I also have central apneas.  So my doctor sent a request for a lab study.  The insurance denied that one saying it was not medically necessary.  The doctor ended up doing a "peer to peer" with my insurance to get it approved.   After all that I went to schedule the sleep study and they reject me because it was longer than six months since I had an office visit with my doctor.  I make a new appointment, go to the doctor, he orders a new study, and I finally go to the sleep lab.

This was my fourth study over the years and the worst one yet.  Firstly it was a split study as for some reason they needed to verify I still had sleep apnea.  I wasn't comfortable and had some pain issues so it took almost three hours for me to get enough sleep for them to diagnose me with an AHI of 113.  Then for the second part they provided CPAP.  I still wasn't comfortable but slept for three of the four hours with 30 reported awakenings.  They ended up with a CPAP pressure of 13 which took my AHI down to 2.  The AHI number sounds good but since I wasn't able to really sleep it feels like it was a waste.  In the notes they reported that my times in different sleep stages were abnormal which adds credence to my feeling of poor sleep.  I spoke with my doctor's assistant about this but all she could do is flag it for my doctor and I am waiting to hear from him on what is next.

Today I saw that with that one night the sleep center billed my insurance $4400.  Using round numbers the allowed amount was $1500 so they overbilled by almost $3000.00.  I have a BCBS plan that pays 80% but only after meeting my deductible so my out of pocket is going to be over $600.

I keep on going but am frustrated with all of this.  I just realized it has been over a week that I haven't heard from my doctor's office.
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#2
RE: Rant about insurance, sleep study, and costs
In most cases of central or complex apnea, the titration study finds a pressure that works "good enough" and you end up with CPAP when you still need ASV. I can almost guarantee from your story that CPAP won't work. All of that money down the drain and you won't be done. Of course you could have bought a new Resmed CPAP for about the same money out-of-pocket.

Get a detailed copy of the study, not just a summary. You paid for it. Never let them do that to you again.
Sleeprider
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#3
RE: Rant about insurance, sleep study, and costs
(05-05-2023, 07:21 AM)Sleeprider Wrote: In most cases of central or complex apnea, the titration study finds a pressure that works "good enough" and you end up with CPAP when you still need ASV.  I can almost guarantee from your story that CPAP won't work.  All of that money down the drain and you won't be done.  Of course you could have bought a new Resmed CPAP for about the same money out-of-pocket.  

Get a detailed copy of the study, not just a summary. You paid for it. Never let them do that to you again.

Unfortunately I've been through this before.  My first study came up with a diagnosis of complex SA.  Even with that they gave me a standard CPAP machine with which I was able to fall asleep but would always wake up gasping for breath.  I was told at the time there was nothing else they could do so I gave it back.  In 2010 I found a new doctor, had a new sleep study, and got a BiPAP ASV Advanced which I was able to use and brought my AHI down to around 4 if I remember correctly.  Then in 2014 I got my current System One and changed to a P10 pillow which helped even more and my AHI is averaging around 1 lately.

I did get the 10 page report.  Two snippets attached.  The diagnosis was OSAS with no mention of central or complex even though the numbers showed CAs.  Also showing 0% REM without therapy, then with the final pressure of 13 I got the only REM sleep of the night.  Odd and noted on the summary was 0% N3 sleep with or without PAP.  Oxygen levels came up to 91% at the end with 13 cmH2O.  Also interesting is that the snoring episodes are showing 0 but mentioned in the summary and recommendations is that I do snore.

After contacting my doctor's office today they are saying that they are waiting for clarification of the sleep study report.

Thanks for listening.


Attached Files Thumbnail(s)
       
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#4
RE: Rant about insurance, sleep study, and costs
Approx 1/3 of your apneas are central.

Post the whole report so we can give you a better read
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#5
RE: Rant about insurance, sleep study, and costs
I can find efficacy in any individual with complex apnea. Just let me write the report.  Your results show complex apnea without therapy, and fairly quick abatement of CA and OA with CPAP pressure, which is replaced by hypopnea up to 13 cm where that is apparently extinguished. Normally I don't see such linear results with complex apnea, and while the results look good for an hour or so, I'm certain they will fail in practice.  For someone previously treated with ASV, it's amazing they are taking this back to the beginning with CPAP and you will end up going through the entire process again.  Just disappointing.

[Image: attachment.php?aid=50440]
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
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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.
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#6
RE: Rant about insurance, sleep study, and costs
The site wouldn't let me upload a pdf or a big document so I put it on a hosting site.

Here is the report with names redacted (remove the space after https:):  https://www.sendbig.com/view-files/?Id=9...b0341a57ce  
    --  password is central
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#7
RE: Rant about insurance, sleep study, and costs
The hypngram you originally posted told us most of what we needed to know. Looking at the study, there is no remark about your 14prior history of using servo ventilation therapy. The study appears to have found an hour of low events at 13 cm CPAP pressure. What this means of course is that you will be dispensed CPAP and to progress to a different therapy will have to fail CPAP with a high AHI. Noted that you experienced no REM sleep. The oximetry and sleep stage graphs were not useful at the presented resolution.

Your study does not offer a diagnosis. You should discuss this with your doctor and request that the record show you have been diagnosed with very severe complex apnea. This will help in the event you need to change your therapy back to ASV later.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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.
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#8
RE: Rant about insurance, sleep study, and costs
Yes, an hour of low events and victory was declared over my sleep apnea. The rest of the data doesn't matter, I guess.

They did include "DIAGNOSIS: Obstructive Sleep Apnea (G47.33)" so everyone can get paid. I am sure that they have a template they use with OSA reports which is why they didn't mention the any of my central events.

I discussed with my doctor's office that the report had issues (and not wanting standard CPAP) so they were to push back. I am now waiting for what my doctor comes back with.

Thanks for your feedback and support.
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#9
RE: Rant about insurance, sleep study, and costs
Sounds right. Just look at 30 min - 1 hr of data and proclaim issue solved. Been there, done that. It doesn't work. Sad It's a sad state of affairs.
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