I recently finished my second sleep study (1st one didn't go so well as I had an abscessed tooth that started on the night of the study, needless to say I didn't get any sleep). I spoke to the Doc after the results came in and apparently I don't have a high enough AHI, only 1.9, to be deemed as having apnea as a result of this study. Although, I had many Respiratory Effort Related Arrousals (RERA's). They'd like to try me out on a CPAP to see if it helps. He wrote me a script for a CPAP and I contacted a supplier to get the equipment. The supplier called me back and told me that the DME Co. turned me down because my AHI was too low.

Now, I know I have apnea at times. My wife tells me about it and I actually wake during some nights gasping for air. I'm falling asleep at my desk during the day........Pretty much all the classic symptoms. It just turns out I did really good (or not so good depending on your perspective) during this study.

I'm going to contact the Doc tomorrow and get the actual results of the study for reference. Then I guess I'll contact the DME and find out whether they base coverage solely on the AHI or whether a doctor can override this and what needs to be done for that to happen.

Has anyone run into this problem before? Any information would be greatly appreciated.
Are RERA's taken into account during diagnosis?
Can A CPAP help with RERA's?

I'll ask to be tested again but I'm wondering how many my insurance co. will pay for since I already had two, and like I said, my symptoms do not occur every night.

Thanks

Just to clarify, DME stands for Durable Medical Equipment, meaning the folks who sell medical equipment such as CPAPs.

So you mean your insurance company won't pay for the CPAP?

With an AHI of only 1.9, I can see why they are denying it. But what you need to push for is for them to not see the CPAP as treatment for sleep apnea, but for the other condition. CPAP = treatment for SA in their book, literally.

From the things that I have been reading, RDI is actually the best index to use rather than AHI.  RDI would include your RERA's.  What was that level?

I'm guessing that the doctor will have to provide to the DME (and thereby the insurance company) some sort of report describing the medical necessity, which I suspect will include RDI and a report of symptoms.  Apparently most insurance companies require evidence of symptoms to pay for a titration and equipment, even for mild sleep apnea.  The DME may just need the right documentation from the doc.


Linda


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Sorry, I guess I was a little misleading when I said DME turned me down.  I guess I referred to them that way because the DME administrator is a carve-out of my regular insurance and is handled by "DMEnsion".

Paula, thanks for the advice.  I did end up contacting DMEnsion and had a discussion with one of the reps.  I explained that the CPAP wasn't being prescribed for Apnea but for Upper Airway Resistance Syndrome (UARS), therefore the reason for denial (the low AHI) wasn't really valid.  I felt like I was talking in circles with the rep and finally got her to tell me that CPAP is only covered for Sleep Apnea, and only when the AHI is greater than 5 with other symptoms.  This kinda floored me.  I'm wondering if an appeal citing my plan document that states DM Equipment will be covered based upon medical necessity, which obviously the Dr. feels is warranted, would get me anywhere.

Raymart and Linda, thank you also.  The full polysomnography is supposed to be in the mail to me.  I'll study it and try to make a case for an appeal.  

I guess I have 3 options now:
1 - Give it up and be miserable and tired (NOT!!!)
2 - Get another sleep study done and hope that it actually shows criteria that meet what they're telling me is covered.
3 - Approach the Dr. and ask for more supporting info and resubmit for the CPAP
4 - Appeal

Any advice on what may get this noticed as a necessity by DMEnsion would be greatly appreciated.  Also some tips on the best ways to appeal could help, if anyone has any experience in this.

At any rate, thank you for your help so far.