I mentioned the results of my sleep study in Friday’s post. Sleep specialists use the apnea-hypopnea index (AHI), a scale that tells whether you have sleep apnea and how serious it is. When I was given the results by the doctor who read the sleep study, she gave me the score based on the criteria set by the American Academy of Sleep Medicine (AASM).
Late Friday afternoon, my sleep medicine provider called me to discuss my results. She explained to me that there are actually two scales used. The one the doctor had sent me a message about was the one determined by the AASM, which is accepted by most insurance companies, and according to that scale, I am above the limit for the Inspire therapy implant. However, there is a second scale used by the U.S. Centers for Medicare & Medicaid Services (CMS). This is the scale used by Medicare and Medicaid to determine AHI.
I know all of this may sound technical, God knows it does for me. But the important thing my sleep medicine provider told me was that according to the AHI scale used by CMS, I qualify for the Inspire therapy implant. In other words, if I had Medicare or Medicaid, I’d qualify, but most other insurances don't recognize the CMS AHI as a valid criteria.
Now, just because my insurance Cigna doesn’t normally recognize the CMS AHI score doesn’t mean they can’t be convinced otherwise. So, because I meet all of the other criteria, especially intolerance for the CPAP, she is referring me to the ENT specialist that does consultations for the Inspire therapy at Dartmouth-Hitchcock Hospital. She believes there may still be some hope.
The ENT would still have to do an endoscopy to see if my throat is round enough to meet the last criteria. I will have to consult with the ENT though before she will agree to go forward with qualifications for the procedure and getting it approved by Cigna. I suspect, I will not be able to see the ENT until the new year, but I’m hoping to hear from her office at some point this week.
Fingers crossed!
Quick Update: The ENT doctor’s office called, and I have a consultation on Jan. 10.
5 comments:
Being a persistent advocate for your health is not always easy and health insurance companies can be a bitch. One thing I can tell you from my work experience with health insurance is that these companies are spending millions to "improve the member experience". That usually means redesigning websites and apps, providing perks, etc...
When you talk to managers / supervisors (because you'll probably have to ask for that at somepoint), use their language and let them know this is impacting how you view your insurer when your employer polls you on your satisfaction with them. Tell them these hurdles are detrimental to your "member experience". You may need to also put that in writing if your request requires an appeal.
Thanks for the advice, BosGuy. One summer I worked for a disability lawyer, and this is similar to what I learned from her. She said the the social security/disability office nearly always denies the initial claim because people have to file the claim on their own, and they rarely know the correct language to use in filing their claim. Then their appeal is usually successful because the lawyer who files the appeal knows the correct language to use. When my mother became disabled years ago and could no longer work, she filed for disability, and I told her to use medical language and be as technically accurate as possible in describing her condition (she was a nurse, so she could easily do this). She followed my advice (one of the few times she ever has), and she was granted disability benefits without having to appeal. There’s a lot to be said about using the correct terminology and language to get what you want. I am thankful that my medical providers understand the issues with insurance companies, and they usually know how to handle them when they appeal a decision. Rarely have I been forced to handle these matters on my own.
Good luck, hope you get some good news.
I'm glad there is at least some grounds for hope that you'll be able to have the implant.
I am 73 and tend to take a siesta or 2 during the day which then screws up my need to sleep at night. I found about halfway thru the night if you can´t sleep then read, do the dishes, clean your fridge ... anything that is slightly boring and then go back to bed. It works for me and also lighten up on any alcohol at night as it doesn´t really encourage a deep sleep.
As we get older we need less night sleep and less food. The motor runs very different and one must accept we are changing with little info to assist us as older people.
Good Luck!
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