Requisite CPAP Trial (Fep Blue)

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PierreDeFermat
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Re: Requisite CPAP Trial (Fep Blue)

#16 Post by PierreDeFermat » Fri Feb 02, 2018 11:58 pm

An update:

I called my insurance after two weeks of hearing nothing and they said they reached out to my surgeon's office to schedule a peer-to-peer review but they did not respond.

Has anybody gone through this process? It's been two months since I first consulted with my doctor and I still don't know if the procedure will be covered, let alone have a surgery date...

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

Re: Requisite CPAP Trial (Fep Blue)

#17 Post by PierreDeFermat » Mon Feb 05, 2018 5:26 pm

Called my insurance today and they said they just faxed out an approval to my surgeon's office, I'm over the moon!

I'll try to figure out what happened insurance-wise and report back.

I should mention that my CPAP titration had came back as "CPAP untolerable" and listed my reported reasons for why I could not tolerate the device.

josh5464
Posts: 7
Joined: Sun Jan 21, 2018 12:20 am

Re: Requisite CPAP Trial (Fep Blue)

#18 Post by josh5464 » Mon Feb 26, 2018 12:36 am

[quote=PierreDeFermat post_id=500201 time=1517876801 user_id=31191]
Called my insurance today and they said they just faxed out an approval to my surgeon's office, I'm over the moon!

I'll try to figure out what happened insurance-wise and report back.

I should mention that my CPAP titration had came back as "CPAP untolerable" and listed my reported reasons for why I could not tolerate the device.
[/quote]

good luck boyo, what country are u in btw?

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

Re: Requisite CPAP Trial (Fep Blue)

#19 Post by PierreDeFermat » Mon Feb 26, 2018 10:27 am

I'm in the United States (California).

My surgeon had sent in a letter of medical necessity saying that the procedure was essentially my best option since CPAP was intolerable.

I'm having a segmental Lefort I, BSSO, and a sliding genioplasty to correct my underbite. Counterclockwise rotation (CCW) of the occlusal plane is also indicated.

Only 50 days until surgery!

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

Re: Requisite CPAP Trial (Fep Blue)

#20 Post by snapdresser » Tue Feb 27, 2018 6:16 am

Congrats! :rawk: :rawk: :rawk: Welcome to the wild and wacky ride that is orthognathic surgery :lol:
No braces
1-piece LeFort I + BSSO + Sliding Genio on 10 JUNE 2015!
Image

runrabbitrun
Posts: 44
Joined: Tue Mar 06, 2018 8:51 pm

Re: Requisite CPAP Trial (Fep Blue)

#21 Post by runrabbitrun » Tue Mar 06, 2018 9:08 pm

Congrats on your surgery approval - you must be stoked!

I'm in the same boat as you were - mid-twenties, diagnosed w/ severe sleep apnea in January, and currently battling my insurance to get MMA approval. I'm very fit and active, so weight is definitely not a contributing factor, and both my surgeon and sleep specialist agreed that my bone structure and age made me a great candidate for MMA.

I'm totally with you - seems kind of crazy that sticking someone on a machine for 6 decades is considered "conservative"... on top of that, I also experience airway collapse when I'm working out (which has resulted in me blacking out for a second twice now in the past two months), so to me, CPAP doesn't seem like a real solution. Insurance disagrees, and still wants me to do a 3-month trial. I've been on it for 3 weeks and can't keep it on for more than an hour, on top of the hour it takes me to actually fall asleep with the thing on.

So my question is - can you possibly share more specifics about how your doctor worded your appeal letter so that the trial could be side-stepped? I'm seeing my sleep specialist on Thursday and am hoping they can get this moving forward.

Thanks in advance for your help!

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

Re: Requisite CPAP Trial (Fep Blue)

#22 Post by PierreDeFermat » Wed Mar 07, 2018 3:19 pm

If you're experiencing restricted breathing and/or losing consciousness during exercise I strongly advise you to stop working out until you have consulted with your doctor. Those are serious symptoms and can be caused a variety of maladies which may or may not include maxillofacial deformities.

Second, If you're interested in orthognathic surgery I suggest you pursue that through a reputable maxillofacial surgeon as they will be the one to examine you and submit the appropriate documentation to your insurance (including x-rays, observations, general treatment plan, etc.) and the relevant information collected by your sleep specialist. They will also be able to describe the different treatment options you have and the pros/cons of each as well as answer any questions you have.

My personal steps were:
1. General Practitioner prescribed me a home sleep study which revealed severe sleep apnea. The "sleep physician"* who ran study recommend I be titrated for CPAP
2. I consulted with an in-network maxillofacial surgeon and decided to pursue orthognathic surgery (they submitted pre-approval request to my insurance)
3. I underwent CPAP titration and was deemed "CPAP intolerant" by sleep physician. The report included reasons why I could not tolerate the device.
4. My surgeon's office submitted an appeal which included my failed CPAP titration study and I was approved

My surgeon's office said 99% of claims were denied the first time, but that it was extremely rare that any cases were completely denied after relevant appeals. They deal with insurance day in and day out so they know exactly what to do to get you covered if they surgery is both necessary and covered by your insurance provider. It took me over a month to get my approval.

If CPAP is not working for you, I suggest you tell your surgeon and they will be able speak to your insurance about why you cannot tolerate CPAP (which is common) and why surgery is indicated in your particular case. Three weeks should probably be enough time to judge the efficacy of CPAP, so they may submit to your insurance now. (Again, the surgeon's office will be able to give you the best answer).

*My sleep studies were overseen/reviewed by a doctor certified by the American Board of Sleep Medicine

Best of luck, let us know how it goes!

runrabbitrun
Posts: 44
Joined: Tue Mar 06, 2018 8:51 pm

Re: Requisite CPAP Trial (Fep Blue)

#23 Post by runrabbitrun » Fri Mar 09, 2018 7:00 am

[quote=PierreDeFermat post_id=500780 time=1520461193 user_id=31191]

If you're experiencing restricted breathing and/or losing consciousness during exercise I strongly advise you to[b] stop working out until you have consulted with your doctor. [/b] Those are serious symptoms and can be caused a variety of maladies which may or may not include maxillofacial deformities.

Second, If you're interested in orthognathic surgery I suggest you pursue that through a [u]reputable[/u] maxillofacial surgeon as they will be the one to examine you and submit the appropriate documentation to your insurance (including x-rays, observations, general treatment plan, etc.) and the relevant information collected by your sleep specialist. They will also be able to describe the different treatment options you have and the pros/cons of each as well as answer any questions you have.

[u]My personal steps were:[/u]
1. General Practitioner prescribed me a home sleep study which revealed severe sleep apnea. The "sleep physician"[b]*[/b] who ran study recommend I be titrated for CPAP
2. I consulted with an in-network maxillofacial surgeon and decided to pursue orthognathic surgery (they submitted pre-approval request to my insurance)
3. I underwent CPAP titration and was deemed "CPAP intolerant" by sleep physician. The report included reasons why I could not tolerate the device.
4. My surgeon's office submitted an appeal which included my failed CPAP titration study and I was approved

My surgeon's office said 99% of claims were denied the first time, but that it was extremely rare that any cases were completely denied after relevant appeals. They deal with insurance day in and day out so they know exactly what to do to get you covered if they surgery is both necessary and covered by your insurance provider. It took me over a month to get my approval.

If CPAP is not working for you, I suggest you tell your surgeon and they will be able speak to your insurance about why you cannot tolerate CPAP (which is common) and why surgery is indicated in your particular case. Three weeks should probably be enough time to judge the efficacy of CPAP, so they may submit to your insurance now. (Again, the surgeon's office will be able to give you the best answer).

[b]*[/b][i]My sleep studies were overseen/reviewed by a doctor certified by the American Board of Sleep Medicine[/i]

Best of luck, let us know how it goes!
[/quote]


Thank you so much for taking the time to respond!

Re: your first two points (which are both excellent suggestions) -

1. I gave up running ( :( ) a few months ago, and am otherwise taking it easy exercise-wise. I've already consulted w/ a cardiologist who agreed that these issues are concerning, and have a number of tests scheduled in the coming weeks to determine whether they're sleep apnea related.

2. I was actually already working with a maxillo surgeon *before* getting my OSA diagnosis - I met him for an unrelated oral surgery, and after looking at my patient history, asked whether I'd ever had a sleep study done. This was actually super helpful since, to you point, I felt like he was able to walk me through all my options and potential treatment plans both before and after my diagnosis.


I actually had a follow-up meeting with a new sleep specialist yesterday, and she agreed that MMA surgery is my best option! She shared her chart notes (something like 14 pages about my health history and CPAP issues) with my surgeon so that they could re-submit the surgery pre-authorization to my insurance :) I know I shouldn't be too optimistic just yet, but I'm really hoping that her notes convince them to change their mind about the 3-month trial requirement.

Thanks again for your help - it's reassuring to know that someone else went through the same process, and that there is hopefully a resolution!

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

Re: Requisite CPAP Trial (Fep Blue)

#24 Post by PierreDeFermat » Fri Mar 09, 2018 9:27 am

Great, it sounds like you should be very excited!

Having multiple physicians confirm your diagnosis/treatment plan is great sign and getting approval should be very routine for them. Even if it's another 6 months before your surgery date that's short compared to living the rest of your life impaired.

In the meanwhile I suggest you do some research on the specifics of your surgery and prepare some questions for the doctor before you see him/her; there are both functional and aesthetic goals that need to be reached, so make sure you tell your doctor exactly what you expect from the surgery.

runrabbitrun
Posts: 44
Joined: Tue Mar 06, 2018 8:51 pm

Re: Requisite CPAP Trial (Fep Blue)

#25 Post by runrabbitrun » Thu Mar 15, 2018 8:22 am

[quote=PierreDeFermat post_id=500822 time=1520612859 user_id=31191]
Great, it sounds like you should be very excited!

Having multiple physicians confirm your diagnosis/treatment plan is great sign and getting approval should be very routine for them. Even if it's another 6 months before your surgery date that's short compared to living the rest of your life impaired.

In the meanwhile I suggest you do some research on the specifics of your surgery and prepare some questions for the doctor before you see him/her; there are both functional and aesthetic goals that need to be reached, so make sure you tell your doctor exactly what you expect from the surgery.
[/quote]

You weren't wrong... surgeon called last night to tell me it's been approved!! I'm in shock. It took them a week to review and deny the first time around, so I'm kind of floored that they reviewed and approved in 24 hours. Makes me think my new sleep specialist/neurosurgeon really went to bat for me, which is awesome. Finally feeling like all this time and research and back-and-forth paid off!

Now, the crazier part -- turnaround time is FAST. They're able to squeeze me in for a pre-op appointment this afternoon, and can possibly get me in for surgery as early as April 4th. I asked a ton of questions at my first meeting about a month ago (went over the basics of the surgery and timeline and any of my major concerns, as well as aesthetics), but I'm sure I'll have more now that I know the procedure is a reality. Is there anything you thought was helpful to ask about that doesn't seem obvious?

Thanks again for all of your help!

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

Re: Requisite CPAP Trial (Fep Blue)

#26 Post by PierreDeFermat » Thu Mar 15, 2018 12:56 pm

Wow that's incredible, congratulations!

I recommend you consider at least doing some research on the specific movements your surgeon is proposing and even get a second opinion if possible. (I don't mean to scare you, but when it comes to orthognathic surgery there are plenty of hacks out there, so I urge you to read up on reviews and choose a doctor wisely). Tell your surgeon EXACTLY what you expect from the surgery, and don't be afraid to walk away if something doesn't feel right.

I also encourage you to start a thread with the specifics of your journey so that other people can read about your story.

Best of luck

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