Will Medicare Cover 2nd Opinions on SA Diagnosis?
I got a G47.33 diagnosis with:
CA= 5.7
OA= 0.3
Hypop= 7.3
A+H= 13.2
RERA= 8.1
Sleep study with CPAP:
CA= 3.3
OA= 0.0
MA= 0.3
Hypop= 3.9
A+H= 7.5
RERA= 4.5
New to this, but seems to me A+H is still almost twice what is desired using cpap.
RE: Will Medicare Cover 2nd Opinions on SA Diagnosis?
Without seeing a detailed listing of the data used to generate your numbers, any observation would be speculation.
- Red
RE: Will Medicare Cover 2nd Opinions on SA Diagnosis?
Mainly wondering if insurance would cover 2nd opinions.
RE: Will Medicare Cover 2nd Opinions on SA Diagnosis?
The G47.3 diagnosis is obstructive sleep apnea and was determined during your diagnostic sleep study. A follow-up titration study with CPAP found a treated AHI of 7.5 events per hour. The reality is that the majority of your problem is central apnea, and it is a safe bet that the hypopnea events are actually central breathing suppression rather than obstruction. The diagnosis of patients with predominately central apnea as obstructive sleep apnea is extremely common, and explains why CPAP titration was unable to produce good efficacy. Individuals with CSA need a bilevel machine that produces backup breaths, by switching to a higher inhale pressure (IPAP) on a timed or adaptive basis. Those machines are expensive, and the normal course of therapy is to start patients on CPAP. The truth is, a titration test is just a formality, but in your case demonstrates that CPAP does not produce acceptable results.
Your next move should be to ask the physician why he diagnosed you with obstructive sleep apnea, when you have predominately central events, and given the failure of CPAP, ask when a titration evaluation on ASV will be performed. ASV is an adaptive servo ventilator, that increases pressure when a spontaneous breath is not initiated by the patient when needed, as needed. It is pretty clear they intend to issue a CPAP and see if time changes the results. It sometimes is possible for individuals with mild CSA to achieve efficacy with CPAP, however CPAP often makes the problem works as it improves ventilation. Your tests could be reviewed by a second physician, and that is generally covered by Medicare. Your objective should be to modify the diagnosis from obstructive to mixed or central apnea.
RE: Will Medicare Cover 2nd Opinions on SA Diagnosis?
Thanks
I thought I read somewhere, maybe on this board, that Medicare only wants to cover a CPAP first, and then see data that shows it "failed", before covering more expensive BiPAP, and then ASV. Maybe that is why doctors commonly give an OSA diagnosis over CSA diagnosis, and why a 2nd opinion wouldn't necessarily change a Rx from a CPAP.
