Second opinion on a sleep study

[spudhorse]

Hi all,

I'm trying to get a second opinion on a sleep study since there's a concern about whether the machine I've been supplied is the best machine for my apnea. I simply want someone else to look at my existing sleep study and tell me their recommendation for equipment and settings.

Has anyone gone through this? Any hints?

What I've been running up against are:
1) Medicare won't let us do telemedicine visits when it involves CPAP. [Insurance says "What? Never heard of that!"] [SEE NOTE]
2) I tried a large clinic in another state who said "our doctors aren't licensed in your state." ["Probably couldn't write a prescription for you."]
3) In my state, "we can't make an appointment without a referral." [Insurance says "No referral needed to see a specialist."]

NOTE: I think this might be an interpretation of Medicare rules that require "The patient must have a face to face evaluation with a physician of their choice" and whether a video conference is "face to face." Also, the rules seem to have been relaxed in 2023 and audio only might be sufficient but I'm not clear on that.

[Gideon]

1. BS. Since Covid Telemedicine has been accepted, though I think (don't know) they can charge more for an in-person visit.
2. They can write the prescription, the question is could you fill it?
3. The issue with referrals are that your insurance may require them, you said your's does not. I think you need a new doctor at a different facility.
I imterpet face to face as it must be twoway realtime communication.

If you post it here we would be glad to help.

[SarcasticDave94]

The sleep study you've done already that's posted in the other thread, clearly states you have severe Apnea. It mentions there was Central and Obstructive Apnea, likely CA were observed at about 50% in the diagnostic portion of the split. You were issued an ST, skipping CPAP and BPAP. The report mentions if ST fails to treat, ASV is next.

I could not suggest taking another sleep study. Rely on what they have said and make them issue the ASV.

I know you want others to comment, but the other thread makes it pretty clear you'll need to put your boxing gloves on and fight them until you get ASV.

[Sleeprider]

Spudhorse, it might help if you read the Dealing With A DME wiki. https://www.apneaboard.com/wiki/index.ph...with_a_DME
and Medicare and Insurance https://www.apneaboard.com/wiki/index.ph...6_Medicare

It seems you're being given a typical run-around that will get you nowhere. My favorite tactic in these cases is to have the insurer call the doctor or provider and set them straight, or to find a new provider.

[dataq1]

Do you have traditional Medicare or Medicare Advantage?

My wife (on Traditional Medicare) had an in-lab sleep study (referred by PCP), was subsequently assigned to a sleep doc. The Sleep Doc met with her via zoom and sent an Rx to a local DME. She zoomed with him about 30 days after, and has had all her follow-ups with him via zoom. That was two years ago. No issues with traditional medicare.

[spudhorse]

Thanks Gideon. Evidently, Medicare does require a "face-to-face" for establishing the need for CPAP. I haven't been able to find out directly whether this rule falls under the televisit rules that were adopted under Covid. I'm trying to see if my insurance company can provide any additional information.

Also --

https://www.medicare.gov/coverage/contin...re-devices

Medicare may cover a 3-month trial of CPAP therapy (including devices and accessories) if you’ve been diagnosed with obstructive sleep apnea. After the trial period, Medicare may continue to cover CPAP therapy, devices and accessories if you meet with your doctor in person, and your doctor documents in your medical record that you meet certain conditions and the therapy is helping you.

Again, it would seem that this has likely been changed under the Covid changes. It's certainly not unusual to find conflicting government requirements!

I'm working on finding a different doctor although my options are very limited in Idaho which is why I called a large clinic in Utah and got the "we're not licensed in Idaho." It turns out that same hospital system had no trouble getting me in for a $150K cardiac ablation and Costco had no trouble filling any prescriptions!

The entire saga of my sleep study is at this link.

[spudhorse]

Sleeprider: The problem is that I'm dealing with a Physician's Assistant who's dumb as a post and covering his butt. It's not a DME problem. I also don't have a "sleep doctor". 

Dataq1: I have an Advantage Plan. They've been nothing but helpful.

Sarcastic: The problem is that there's no one to box with. More details in the other thread. Really appreciate your help.

What I was really interested in here is "has anyone gotten a second opinion on a sleep study?" It seemed an easy thing to do and then I could go back to the PA and say "maybe you should rethink your decision." On the other hand, maybe it's just really rare to get a second opinion for this.

[SarcasticDave94]

If it helps any, I've fired and replaced several sleep pulmonary docs. Each said they wanted a sleep study. I was dumb and complied, because I wanted proof of the machine I need. Each study revealed less need to treat, with each doctor progressively less interested in doing anything more than tests.

Insurance was billed over $32K for the tests with no machine issued. What I should have done was use the sleep study report from 2017 and say here's the info.

More tests may provide more info or it could backfire and seemingly prove you don't need it.

Side note, my case is complex. I do have Obstructive and Central Apnea along with Emphysema COPD. So more tests mean zero. It's been a huge waste of my time and effort. Most sleep specialists have the title and patients as a side job. Their only specialty is billing you for mediocre treatment.

[spudhorse]

Good point on the sleep study. I think it would be a toss-up between doing another sleep study and being waterboarded. 

[Sleeprider]

ASV is appropriate for complex (central and obstructive) apnea and would likely work well for you unless you also suffer from hypoventilation. If you have complex apnea with the potential for hypoventilation or insufficient respiration to maintain SpO2, then iVAPS as provided by the ST-A is indicated. More studies would not help in this kind of decision, and frankly, if you were to be dispensed an ASV machine and recording oximeter to evaluate its efficacy, all requirement would be met. The decision for ASV could be revisited if it not not prove effective. Get the Rx of ASV by discussing with your doctor, or I can help you source a reasonably priced used machine to self-demonstrate efficacy so you can get this process moving and get approval with evidence of efficacy.