UARS & Insurance

[LS1thunder]

I am needing to know if anyone has had any luck with insurance paying for UARS related treatment. I have Blue Cross BS and I have read that they treat UARS like Apnea. My ENT said they will not pay for any treatment of UARS. Which is it?.

[dopey]

LS1thunder,

If you have been diagnosed with UARS, you should have completed a sleep study. What is your RDI (respiratory disturbance rate)? That should include apnea, hypopnea and respiratory (UARS events). If it is greater than 5/hr. the usual first line treatment attempt is PAP. If you can find that data and it is greater than 5, call you insurance company and ask them.

[LS1thunder]

Dopey,
Yes I had a PSG. My RDI was only 1.9/hr for Apnea, but, I had 64 EEG arousals for an EEG Index of 12.8/hr. So, I am waking myself up prior to an Apnea event. My diagnosis was Snoring and UARS.

This is why I'm asking, does/will the Insurance company consider UARS a disease and will they pay for the treatment if I go forward with it?

[dizzy]

FYI: Most Insurance will NOT pay for procedures related to snoring alone as it is NOT considered a medically necessary treatment or disorder. RDI is also not recognised by most insurance either, RDI was "proposed" by Colin Sullivan and never generally adopted by the sleep industry. Some labs & doctors use it but most rely on AHI index when it comes to insurance and OSA.

Below is an exerpt from Blue Cross's medical policy:

"Section II: "When treatment of sleep apnea and breathing related sleep disorders is not covered"; C.4 now reads "Palatal stiffening procedures, including but not limited to, cautery-assisted palatal stiffening operation (CAPSO), and the implantation of palatal implants, are considered not medically necessary in the treatment of snoring alone, and are considered investigational as a treatment for UARS or OSA." Under same section removed C.7 "Cautery-Assisted palatal stiffening operation (CAPSO) is considered investigational." since it is now included in C.4 above; previous items C.4, 5 and 6 were renumbered to 5, 6, and 7 due to the changes. Reference source and key words added."

You can find the link here:
http://www.bcbsnc.com/services/medical-policy/updates/medical-policy-updates-2005-06-16.cfm

You can go to the above link and search for the disorder to find out if they cover the procedure. Payment-wise, your best bet is to be found to have OSA then they can treat your snoring and they will pay for it (this industry is a racket).

[Sleepy Stoboy]

Just for the record, I have Blue Cross of California, and they paid for the pillar implants in full after the first submission by the doctor.

Your mileage definitely can vary, but it is not a definite that they won't pick up the tab. Your doctor can call in for a pre-authorization.

However, my treatment wasn't for UARS, and I did have a severe level of apnea diagnosed.

[Toth]

Alot of insurance and sleep testing procedures seem absurd.

I went to one sleep lab that had two reserved parking places for sleep patients but did not send them free bus tickets so as to avoid their having to drive automobiles.

I had a sleep lab schedule me for a test where they wanted me to bring my own equipment but the letter they routinely send out said not to bring any equipment.

And ofcourse these narrow minded insurers do sometimes like to say that any RDI of less than 5 is 'not treatable' and not covered by insurance. There are alternatives even if you find that your policy is overly restrictive. UARS is oft described as occuring in a brain that is so supersensitive to apneas that the arousal occurs prior to the equipment detecting any apnea. One possible thing is to change the sampling rate for the SaO2 and see if that puts you over that magic RDI of 5.0 or not. The other is to remind the insurance company that you do have a defined sleep disorder and failure to treat it will lead to future medical expenses that are far more expensive than the care you need now.

Good luck. And whatever you do, be sure to get it in WRITING from your insurance carrier.

[ChumpChange]

Sleepy Stoboy, you said BCBC paid for pillar........Do you know the name of your plan? And is it a HMO or PPO?