ASV is now experimental - Aetna clinical policy bulletin Feb 08, 2024

[00derek]

Aetna insurance denied my DME's final claim for my ASV in February, after approving the prior 10 claims, beginning May 2023.

The EOB stated the following;

General remarks; "Aetna doesn't cover health care services and procedures that are:

- Experimental in nature
- Still under investigation
- Not proven to be effective
There must be medical proof they help people maintain (or return to) better health. At this time, the
services and procedures aren't proven effective to treat your condition. This amount is your
balance if you signed an agreement with your provider to pay for non-covered services." 

Needless to say I found this inexplicable and so I appealed. The decision on the appeal arrived in the mail today and only now does it start to make any sense.

Long story short, on 2/8/24, Aetna changed their coverage such that my ASV is now considered an experimental therapy. The letter references this document; 

https://www.aetna.com/cpb/medical/data/1_99/0004.html

Cutting to the chase, here is the relevant section;

1. Treatment

• The following are considered experimental, investigational, or unproven for the treatment of obstructive sleep apnea (OSA) in adults because the effectiveness of these approaches has not been established:
  

1. 1. A BiPAP device with a backup rate feature (e.g., adaptive servoventilation, VPAP Adapt SV) (see CPB 0452 - Noninvasive Positive Pressure Ventilation)
      

I don't really know what else to say. I'm lucky they approved 9 tenths of the claims before changing their policy. But in practice my high deductible meant I paid out of pocket anyway. This denied payment would only go to the deductible for this year as well, if it had been approved.

I'm going to appeal again anyway - my diagnosis includes central as well as obstructive apnea.

[Sleeprider]

The ASV is not intended to treat obstructive sleep apnea. It is intended, and is effective int he treatment of complex sleep apnea, central sleep apnea and periodic breathing. An internet search like "Efficacy of Adaptive Servo Ventilation Therapy (add condition optional" will turn up many published studies and findings. The articles often focus on congestive heart failure, cheyele stokes respiration, idiopathic central sleep apnea, complex sleep apnea, but the point is they are in recognized medical journals. Aetna does not get to reinvent the science unilaterally in order to limit their financial exposure.

If you need help obtaining ASV out-of-pocket, let us know. DotMed has been a good source for members.

[sauerkraut]

Typical !! You pay insurance companies, Then when the time comes to
to pay benefits Your intitled to .. They act like Your pulling there teeth
without novacaine !!

I say it all the time .. The two worst things that ever happened to this Country
are lawyers and insurance companies !!

[00derek]

As I said, a high deductible insurance plan means I'm paying out of pocket anyway. All I've really lost is $250 going towards that deductible, but we're 7/12 of the way through the year and I'm only 20% of the way through the deductible, after which Aetna starts paying out.

But I still intend to appeal on the grounds I also have central and complex apnea apnea.

[SarcasticDave94]

Did your prescribing physician diagnose you with Central Apnea, Complex, or Mixed Apnea? Or just Obstructive? If Central Apnea treatment isn't on the order, this can be the source of the experiential thought.

[00derek]

Here is my diagnosis copied from the doctors report;

G47.33 Obstructive sleep apnea (adult) (pediatric) 
G47.31 Primary central sleep apnea 
G47.37 Central sleep apnea in conditions classified elsewhere 
G47.10 Hypersomnia, unspecified

The DME told me that the first time they submitted a claim, they used only the obstructive sleep apnea code. Aetna was fine with that for all the claims except the last claim, which was submitted just after they released their bulletin where they changed policy. When that claim was denied the DME appealed and submitted all of my medical records, including all the other codes. But Aetna either didn't spot the other codes or didn't care.

I'm on appeal number 2 and I've highlighted that I also have central sleep apnea, which was not mentioned in their bulletin and thus for which ASV is not treated as experimental therapy.

[SarcasticDave94]

DME, new way to spell DUMB