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Insurance Denial for CPAP; advice appreciated

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Insurance Denial for CPAP; advice appreciated

Postby melissaenderle » Mon May 03, 2010 10:39 am

In April I had a sleep study with CPAP titration, a followup to the initial diagnostic test last February. I just received an email from my insurance, denying coverage of the CPAP machine. This was a second level appeal. I am perturbed that they can deny coverage for a treatment recommended by the doctor, just because I have UARS, not sleep apnea. The resulting fatigue is just as debilitating as it can be for sleep apnea sufferers.

This is what the letter said:
1. CPAP did not improve your symptoms of frequent sleep arousal / non-restorative sleep from UARS in a significant, clinically measurable way;
2. CPAP is not covered by your plan benefits for the diagnosis of UARS;
3. There is no preponderance of clinical study evidence to demonstrate that CPAP is the medically necessary and preferred treatment of UARS, over other lifestyle modifications.

• How would you interpret the numbers? Is there any validity to their claim?
• Have you been denied coverage and if so, did you have any success in appeals?
• How would you respond to the insurance's claim?
• Any alternative treatments work better?

A frustrated, fatigued individual

Total time in bed: 595.5 minutes
Total sleep time 370.5 minutes
Sleep efficiency: 62%
Stage I: 16.2%
Stage 2: 46.7%
Stage 3: 20.6%
REM: 16.5%

No apneas or hypopneas
Arousals: 121 index: 19.6
Awakenings: none listed
Arousals + Awakenings: 121 index: 19.6
REM awakenings: 0

Interval 1 - 4.0 cm H20: TIB 30 minutes, TST 26.5 minutes. 14 arousals +AW, index 31.7
Interval 2 - 5.0 : 60 59.6 15 , index 15.1
Interval 3 - 6.0 : 181 minutes, 55.5 . 18 , index 19.5
Interval 4 - 7.0 : 39.5 26.5 .10 , index 22.6
Interval 5 - 8.0 : 15.5 13.5 10 , index 44.4
Interval 6 - 9.0 : 31.5 19.0 8 , index 25.3
Interval 7 - 10.0 : 62.5 61.5 7 , index 6.8
Interval 8 - 11.0 : 113.5 94.5 33 , index 21.0
Interval 9 - 12.0 : 48.0 14.0 6 , index 25.7

No leg movements, BMI 19.9, low hanging uvular with Mallampati III, tonsillar size grade 1 on both sides. I have allergic rhinitis, chronic sinusitis, and fibromyalgia.
Mouth breathing was observed at a pressure above 10.

Based on this, the doctor recommended an automatic CPAP machine with A-Flex system 1 cm H20 and heated humidifier. Pressure between 8 and 18. Nasal pillow such as Swift LT. To control allergies, Nasonex was recommended to be continued, along with Allegra and Stillnox.

My sleep study last February:
No REM sleep.
Supine: RERA 19 times/hr, arousal index 20 times/hr
Lateral: RERA 17 times/hr, arousal index 24 times/hr
Stage 1: 46.6%
Stage 2: 29.9%
Stage 3&4: 23.5%
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Postby ApexAZ » Mon May 03, 2010 4:07 pm

Maybe a dental device would be approved? Other than that I don't know what you can do with your insurance company. Have you considered purchasing a new cpap out of pocket? I found the previous respironics M series model auto's online fr < $600. That's a lot to shell out I know.
Severe OSA
19/15 cmH2O
PR SystemOne BiPAP Auto
F&P Forma Full Face Mask
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Postby CrohnieToo » Mon May 03, 2010 5:43 pm

Yup, the new Resmed S9s are out now as well as the new PR SystemOne's so there are some good online buys on the Resmed S8 AutoSet Vantages, S8 Autoset IIs, Respironics M Series Autos w/C-Flex and M Series Autos w/A-Flex. Anyone of those 4 APAPs would do the job you need done and would meet your doctor's recommendation. Why continue to suffer? Forget insurance and buy online outta pocket and get the therapy you need.

I would suggest, altho considerably more expensive, that you buy your first mask out of pocket from a local DME provider which has a lenient mask exchange policy to find "the" right mask for you. Once you find the mask that works well for you you can purchase on line considerably cheaper as well. Online mask exchanges are just not really feasible in my opinion. Some online providers do have exchange insurance but the cost of the insurance is prohibitive in my opinion. At least w/a local provider you can try several masks BEFORE you commit to taking one home and you should have 30 days to exchange it if it doesn't work out for you over the long haul (29 days).

Goshes, I had a Respironics pre-M Series Auto w/C-Flex that I put less than 225 hours on (I bought it brand new as a back up for my Resmed S8 Elite w/EPR) but then was switched to a bi-level and I sold that pre-M Series Auto for $350 complete, case, humidifier, etc., etc. The pre-M Series was a much better device than the M Series.
ResScan 3.10 - Resmed S8 ResLink & oximeter
ConTec CMS-50D+ oximeter - Philips EverFlo 5L Oxygen Concentrator
PR SystemOne BPAP Auto w/Bi-Flex & Humidifier - EncorePro
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Posts: 7943
Joined: Mon Mar 20, 2006 9:18 pm
Location: Mid-Michigan
Machine: Resmed S8 VPAP Auto
Mask: Resmed Quattro FX Small
Humidifier: Resmed H3i
Year Diagnosed: 2006

Postby melissaenderle » Mon May 03, 2010 6:07 pm

I bought a CPAP and related supplies in India last March out of my own pocket - about $1600. A BIG markup, due in part to customs fees. When I get back to the US this summer, I'll check with a local provider regarding a new mask. I am a very sensitive light sleeper and the pulmonologist in Bangkok recommended trying a nasal pillow type. I will ask the sleep specialist I'll be seeing in WI about the dental device. I should be able to get that made cheaper in India, I would think. It would be nice if the insurance would cover that.
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You could try some other method

Postby SnoringProblemFinished » Tue May 04, 2010 3:28 am

Hi friend.

Did you try some other method?
They say CPAP is a surefire solution, but the thing is - it´s just too expensive.

Maybe an adjustable bed, a special pillow, or some natural product?
I heard there are some natural methods out there that help with this problem. They are inexpensive, and they are said to treat the cause of this problem, not just the symptoms.

Maybe if you search around you could find something helpful, and avoid shoping another CPAP.

I wish you find a solution to this problem so you can have a nice sleep :-) .

Kind regards
Hi there!
I have put up a squidoo lens about this subject.
I would really appreciate if you visited it!
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Postby melissaenderle » Tue May 04, 2010 7:59 am

Have you heard of some alternate treatments deemed beneficial? I am having a wedge pillow being made (in India) which might also help the LPR acid reflux they suspect I have.

Looking forward to a good sleep - whenever that happens.
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