Requisite CPAP Trial (Fep Blue)

This forum is for discussions relating to oral surgery for orthodontics.

Moderator: bbsadmin

Message
Author
PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Requisite CPAP Trial (Fep Blue)

#1 Post by PierreDeFermat » Sat Jan 06, 2018 2:39 pm

I'm in my early twenties and have recently been diagnosed with severe sleep apnea (REI 37.7, OAI 21.6) and decided to see a well-renowned oral surgeon regarding MMA surgery as treatment. I have Federal Blue Cross Blue Shield (Fep Blue) insurance and my doctor recently submitted a pre-authorization for Lefort 1, BSSO, & Genioplasty to correct my airway/deficient chin, though I noticed one prerequisite for the surgery which I have not yet fulfilled:

"...mandibularmaxillary advancement (MMA), may be considered medically necessary in appropriately
selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal
obstruction who have [b] failed an adequate trial of CPAP or failed an adequate trial of an oral appliance[/b]."
(Fep Blue Policy manual, 7.01.101)

Has anybody been tripped up with this while filing a pre-authorization? What did your insurance define as a failed trial of CPAP? Did you have any CPAP complications such as claustrophobia, tendency to take off the mask while sleeping, etc?

During my consultation I told my doctor that I wasn't into using a mask or appliance for the next 65 years and he agreed the surgery was the best treatment for me at my age/structure, so I'm hoping that their office might have written it up in a such a way that I can side-step that condition. I should also mention that my occlusion was corrected 10 years ago via Damen braces and I have a documented deviated septum.

User avatar
bbsadmin
Posts: 3398
Joined: Sat Aug 28, 2004 7:03 pm
Location: Northern California
Contact:

Re: Requisite CPAP Trial (Fep Blue)

#2 Post by bbsadmin » Sat Jan 06, 2018 5:06 pm

I have been using a CPAP (actually, now it's an APAP) for about 7 years.

The first month is the hardest to adjust to it. Now I sometimes wake up forgetting that I even have it on. I have a smaller one that I travel with. I wouldn't be without it!

There's a forum on cpap.com that is excellent, if you want more cpap-specific advice.
I'm the owner/admin of this site. Had ceramic uppers, metal lowers ~3 years in my early 40's. Now in Hawley retainers at night!

snapdresser
Posts: 899
Joined: Wed Feb 18, 2015 7:31 am

Re: Requisite CPAP Trial (Fep Blue)

#3 Post by snapdresser » Sun Jan 07, 2018 10:29 am

I also had that requirement for my FEP orthognathic pre-approval, and I believe my surgeon included the information about my CPAP trial in his letter to the approval board. I tried the CPAP for 6 months and kept taking it off at night, literally every single night. I wouldn’t remember it in the morning. It didn’t trip up my preapproval for a Lefort I, BSSO, and SG at all.
No braces
1-piece LeFort I + BSSO + Sliding Genio on 10 JUNE 2015!
Image

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#4 Post by PierreDeFermat » Mon Jan 08, 2018 7:49 pm

Thanks for the responses.

I may have been a little unclear: I have not yet tried CPAP or an oral appliance and my surgeon still submitted the paperwork for pre-authorization last week (I should hear back from my insurance by the 16th).

I'm assuming it will be denied and I'll have to at least try CPAP for a month and see how it works before I can re-submit the procedure, unless the surgeon has somehow contraindicated such a treatment.

Either way I'm excited to finally get some rest at night...

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#5 Post by PierreDeFermat » Wed Jan 10, 2018 7:22 pm

I just booked a CPAP titration (I had it approved by my insurance after my initial sleep study) which happened to be on the very last day my insurance has to let me know the results of my pre-authorization claim for the MMA surgery. I have 24 hours before the titration to cancel, so hopefully I'll find out before then...

Does anybody have some recommendations for CPAP machines/brands while I'm here in case I need to try that first? I believe my insurance will pay to rent one out for me for a period of 30-90 days...

snapdresser
Posts: 899
Joined: Wed Feb 18, 2015 7:31 am

Re: Requisite CPAP Trial (Fep Blue)

#6 Post by snapdresser » Thu Jan 11, 2018 6:30 am

Sorry, I can't recommend any particular brand. Mine was whatever the sleep doc was peddling. Actually, when I stopped using it they never asked for it back and I never got a bill for it either.

Regarding the possibility of them denying your pre-approval, I wouldn't be surprised if your surgeon's letter to your insurance said "The patient's sleep apnea is clearly due to bone structure issues as demonstrated by ___ measurements taken from his x-ray and therefore orthognathic surgery is the only way to fix it." If he/she wrote that, I could see BCBS approving your surgery without the CPAP trial. Hopefully your surgeon has good experience writing letters to insurance. Mine did not but she borrowed a letter written for me by another surgeon and it essentially said the above. Now that I think of it, I don't think it mentioned my CPAP trial. I have BCBS for NY tho, so if you're in another state your mileage may vary.
No braces
1-piece LeFort I + BSSO + Sliding Genio on 10 JUNE 2015!
Image

User avatar
Nozzelnut
Posts: 627
Joined: Sun Jan 26, 2014 10:34 pm
Location: Rochester, NY

Re: Requisite CPAP Trial (Fep Blue)

#7 Post by Nozzelnut » Thu Jan 11, 2018 10:43 am

Most CPAP (APAP) machines are decent. The biggest 2 makers are Probably Resmed and Philip Respironics. Resmed's Airsense auto is a great machine. The PR Remstar 60 would be similar.

The different between APAP and CPAP is the CPAP machines provide one set pressure and the APAPs are variable pressure. The variable pressure is easier to get used to, more comfortable to use and would be recommended. The Resmed Airsense is very quiet, which can be a big deal if you're used to sleeping in that nearly silent environment. APAP's can and will automatically adjust pressure to keep your airway open when you have a "flow limit" or obstructive event. If you get an APAP, you technically don't need to go back for the titration sleep study where they adjust the pressure "manually" while watching you sleep. My first sleep study was a horrible experience. Wires, leads, straps, being exhausted, and the foreign environment was horrible. The people were great and tried their best to make it as positive of an experience as possible; but sometimes the whole thing just isn't good. I opted out of the titration sleep study because of it. OTC sleep aid pills help me get to sleep; I also have Rx'd pills that I only use when necessary which is about 2-4x a year right now...

The machines are typically provided by durable medical equipment providers. Some are in house providers through the same place as your sleep study; some or outsourced to local DME's. Depending on your insurance and how your sleep study provider work would determine where you get your machine.

It's very odd trying to sleep with a mask on your face, connected to a hose, and all the other stuff; the first 30 days are difficult. The first time you wake up in the same position you fell asleep will be memorable though.

MMA is not a guarantee to fix your OSA. For the record.

If you have any questions PM me.
Upper ceramics 5/21/14, Lower stainless 5/28/14
Double jaw surgery was 6/18/15. Estimated time Jan 2016; still on at my 2 year anniversary...

Braces removed 7/20/18; upper and lower Hawley and Essix retainers with bonded lower too.

I'm emphatically against extraction orthodontics! It's easier for the orthodontist; not better for the patient!!!

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#8 Post by PierreDeFermat » Thu Jan 11, 2018 4:46 pm

Thanks for the recommendations, I'll be sure to check them out.

Today I called my insurance and they denied my pre-approval request a few days ago, though I haven't spoken to my doctor's office or received the letter yet to know why exactly why (I'm guessing it's because of the CPAP trial).

When I talk to them I'll see if I can skip the titration and go for the APAP, which will save me at least $250 and a night at a facility...

Did anybody have to appeal a Fep BC/BS denial? I've heard many get denied the first go-around and get it resolved after the first appeal. I called my orthodontist today to have them send over my treatment history in the hope it will aid my appeal.

I should mention I'm in California...

User avatar
bbsadmin
Posts: 3398
Joined: Sat Aug 28, 2004 7:03 pm
Location: Northern California
Contact:

Re: Requisite CPAP Trial (Fep Blue)

#9 Post by bbsadmin » Thu Jan 11, 2018 10:44 pm

I don't know if you could skip the titration. They need some sort of baseline for your AHI and your pressure setting. Also, they need to know whether you have central apnea. It's a lot more complicated than you might think.

PierreDeFermat wrote:Thanks for the recommendations, I'll be sure to check them out.

Today I called my insurance and they denied my pre-approval request a few days ago, though I haven't spoken to my doctor's office or received the letter yet to know why exactly why (I'm guessing it's because of the CPAP trial).

When I talk to them I'll see if I can skip the titration and go for the APAP, which will save me at least $250 and a night at a facility...

Did anybody have to appeal a Fep BC/BS denial? I've heard many get denied the first go-around and get it resolved after the first appeal. I called my orthodontist today to have them send over my treatment history in the hope it will aid my appeal.

I should mention I'm in California...
I'm the owner/admin of this site. Had ceramic uppers, metal lowers ~3 years in my early 40's. Now in Hawley retainers at night!

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#10 Post by PierreDeFermat » Thu Jan 11, 2018 11:50 pm

Skipping the titration was in regard to the APAP machine.

I understand that if I need CPAP I'll have to get it calibrated during a titration study, which was already pre-approved by my insurance.

My initial sleep study included all the relevant apnea indexes, including central apneas.

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#11 Post by PierreDeFermat » Sat Jan 13, 2018 2:18 pm

I received the letter from my insurance as to the reason(s) of my denial, which were that I had not indicated why CPAP mask was intolerable, I have not tried an oral appliance, and have not tried a "less invasive surgery" (in the event that the both CPAP and a splint have failed).

I find it rather ironic that my insurance and their reference medical associations consider the oral appliance and other procedures such as Palatopharyngoplasty "investigational", yet they are required before MMA surgery can be considered. In fact, just under that reads:

"Minimally invasive surgical procedures have limited efficacy in patients with mild-to-moderate OSA and have not been shown to improve AHI or excessive daytime sleepiness in adult patients with moderate to severe OSA." (Fep Blue Policy Manual, 7.01.101)

And in regard to oral appliances:

"... oral appliances have been shown to be less efficacious in patients with severe OSA than they are in patients with mild-moderate OSA." (Fep Blue Policy Manual, 2.01.18)

I have what is considered severe sleep apnea (with all the ancillary symptoms such as daytime sleepiness, difficulty focusing, etc), so I imagine my doctor will only consider CPAP before appealing the denial, though I have yet to speak with their office-- their pre-authorization coordinator NEVER answers the phone or calls me back.

I have my CPAP titration in three days, did you guys have any trouble with the study?

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#12 Post by PierreDeFermat » Sat Jan 13, 2018 3:13 pm

A correction:

"...less-invasive surgeries should be considered prior to the requested procedure," was the original language used in my denial (i.e. "less-invasive surgeries" are not a prerequisite to MMA surgery).

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#13 Post by PierreDeFermat » Sun Jan 14, 2018 4:12 pm

Another correction (since I cannot yet edit posts):

Per the FepBlue policy manual, MMA can be considered if one fails/cannot tolerate CPAP treatment OR an oral appliance, not necessarily both. (Though an oral appliance is recommended if the patient cannot tolerate CPAP).

Just thought I should mention that if anybody with Federal BCBS insurance is considering orthognathic surgery...

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#14 Post by PierreDeFermat » Wed Jan 17, 2018 11:10 am

I just had my CPAP titration study last night. It did not go well.

Because I breathe through my mouth I was titrated with a full facemask, which proved to be very restricting and uncomfortable. While the inhalation was tolerable, exhalation was difficult and claustrophobic, especially with deeper breaths when the mask's "cavity" would fill up before the release valve finally activated (resulting in a rather Darth Vader-esq sound effect). I did manage to get a few hours of sleep but I woke up with a rather dry throat/mouth, and ended up calling the study early.

I spoke to my surgeon's pre-authorization office the day before the titration and they said that almost every one of their cases get denied on the first submission but then gets approved after the first or second appeal. She said the doctor would write a letter of "medical necessity" and include my CPAP titration if it proved relevant (which it did per the above).

Has anybody used an oral appliance for their apnea? Did it have any affect on your occlusion?

PierreDeFermat
Posts: 114
Joined: Sat Jan 06, 2018 2:02 pm

Re: Requisite CPAP Trial (Fep Blue)

#15 Post by PierreDeFermat » Fri Jan 26, 2018 5:26 pm

The doctor has submitted my additional sleep study and a letter of medical necessity in an appeal (not technically an appeal, as my insurance will re-review it with the new information; i.e. courtesy review). Has anybody had any trouble getting approved after the letter of medical necessity?

Post Reply