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Doctor's Appointments and Insurance Guidelines - Sleep Apnea and Chronic Insomnia


#1

Hi there. Concerning sleep apnea and CPAP, I remember reading that insurance companies pay for a person’s visits to their pulmonologist/sleep specialist at the following times: on or after the first month; on or after three months; on or after six months; and on or after twelve months. I would imagine that insurance companies use these specific guidelines to not only make a person “CPAP compliant” (or to cause them to become compliant), but also, to actually help them.

I have my first appointment to see my pulmonologist/sleep specialist tomorrow. My question is, would an insurance company allow a person (and pay for a person) to see their doctor “in between” the “insurance-mandated” time periods (in other words, between month one and month three; between month three and month six; etc.) – if that particular person really NEEDED to see their doctor for an “extra” visit?

So far, after reading quite a bit of literature that I received from my CPAP supplier, the sleep lab, etc., all I see are basically “insurance-mandated” dates (at least what I call them; perhaps I should REALLY be calling them “insurance-recommended” dates). These dates seem to leave absolutely NO “wiggle room” for a person if they really NEED to see their doctor every now and then – OUTSIDE of the “insurance-mandated” dates.

Can a “veteran CPAP user” (or at least someone who is a sleep apnea “veteran”) get back to me on this, so I know how to approach this for my immediate future – and so that I am not just left to worry and speculate about this? I already compiled a long list of questions for my doctor, to the point where I automatically know that I am not going to be given enough time to ask/comment on everything that IS important to me; also, my husband will be coming with me to the first appointment, so I know that HE is going to want to share things, also. Perhaps I should simply photocopy ALL of my comments/questions and just give them to the doctor – so then, I am reassured that he has all of my quests, etc. all “at his fingertips.”

I think that all of this may not be bothering me so much if I didn’t also have “OTHER things on my plate” (like a history of concussions ‘which caused MASSIVE sleep problems for at least twenty years BEFORE I was even diagnosed with sleep apnea;’ PTSD; long -standing anxiety and depression; a husband who wakes up for work at 4:30 am every day; dust, mold and food allergies; etc.). It also seems as some of these “sleep doctors” are ONLY focus on the “sleep apnea” diagnosis (as if it is the only, “end all” problem) – and they don’t seem to address any surrounding, and actually-occurring, sleep disorders that may COEXIST WITH the sleep apnea. I know that a person is certainly more likely to die of sleep apnea (and the terrible conditions that arise from it) and not so much from a more generalized (or specific) “sleep disorder” (such as delayed-onset insomnia, and/or any of the other types of “insomnias” that rightfully DO indeed exist out there). It just seems as if the doctors are concerned with treating the “sleep apnea” PART of a person, instead of the WHOLE person (at least when it comes to their other sleep disorders as well).

I would like to be able to see the “sleep specialist” concerning my OTHER types of insomnia, if at all possible – and I am really not sure if the insurance companies will even let me since they seem to have a rigid monthly and yearly appointment schedule in place once they find that a person is actually diagnosed with “sleep apnea.”

Can anyone out there shed some further insight into this issue for me? Also, can someone let me know if I am wrong about some sleep doctors/pulmonologists NOT addressing the “insomnia” part of the equation (for I really don’t mean to stereotype all “sleep specialists,” especially where the diagnosis of “sleep apnea” is involved)? Thank you SO very much.


#2

Hi @Daisygirl
That’s a lot to mull. Sorry you haven’t received an answer yet.

I will address the sleep apnea/insomnia conundrum… it was found a few years ago that the vast majority (90 percent?) of all patients who had insomnia that was unresolved by medication actually had undiagnosed and untreated sleep apnea.

I’ve seen how this works first hand in the lab: a person says they have trouble sleeping all night… I watch them as they physiologically drift off to sleep on my monitor, then the apneas begin almost immediately, and they awaken and struggle to get back to sleep. To their mind, they are having insomnia, but what they are actually experiencing are apneas that are preventing sleep onset. These are usually people with moderate to severe sleep apnea as well.

This is why the protocol is to identify an underlying sleep apnea condition first. When sleep apnea is corrected, other things may also be relieved (such as insomnia, mood disorders, high blood pressure).
So yes, the priority is sleep apnea first because its therapeutic benefits create a domino of wellness effects.

If the insomnia persists in a person with well-treated sleep apnea, then that is a good reason to reach out for additional help.

Finally, one of the biggest challenges in our field these days is the utter shortage of practicing CBT-i physicians, who are best equipped to handle insomnia nonpharmaceutically. It’s been found that CBT-i (or CBT-i with a limited drug course) is far more beneficial for treating insomnia than drugs alone. However, insomnia complaints far exceed estimated cases of sleep apnea. So yes, they try to rule out sleep apnea first because it will probably fix the majority cases of insomnia, but also… there may not be a CBT-i practitioner in your area, or they may be booked for months out. It is a terrible reality that the governing agencies in sleep health are working hard to find a better solution for.

CBT-i = Cognitive Behavioral Therapy

I hope this helps explain some of they WHY.

Insurance demands are a whole separate can of worms (ugh!) but in a nutshell, they tend to fall in step with whatever Medicare/Medicaid/CMS dictates. This is all up for grabs right now, though, with the healthcare situation in DC extremely fluid under the new leadership. We’re watching and speaking out against changes that would threaten to dismantle beneficial therapies for sleep disorders, you can be certain of that. Stay tuned on that front!


#3

Hi Tamara,

Hopefully, you will read the other message I left for you in response to another message YOU left for me. Otherwise, know that both this message I am leaving you and THAT message that I refer to are linked in some way.

Thank you SO much for letting me know that once the apneas (sleep apnea) is basically resolved, that the insomnia usually resolves itself. With THAT in mind, I think I will work on getting a dental device made for me (after my upper respiratory infection has cleared up and after my MRI is done, in order for my ENT to rule out TMJ – that I mentioned to you in my previous post). I am sorry for any confusion here.

Do you know if CBT significantly helps people who have both insomnia and/or sleep apnea in relation to concussions they have sustained, specifically? I looked for CBT practitioners in my area and, fortunately for me, there are quite a few.

Also, what is your take on getting a neurologist who specializes in sleep involved in my care – in addition to the ENT and the family doctor, and the pulmonologist? Unfortunately, the pulmonologist told both me and my husband that he has never met anyone like me before, and he really does NOT know how to help me; he said this based on the fact that I told him that I have sustained concussions over a twenty-year period and, as a result, my sleep has been tremendously messed up ever since (please refer to previous post I left for you, under previous topic). Also, he made this statement based on the fact that I literally experienced exacerbated and intense ear pain both during, and after, CPAP use (again refer to previous post I left for you). The pulmonologist told me that he knows he had a POOR answer for me (and probably NOT one that I would expect to receive from HIM), but again, he does not know what to tell me – OR do for me in my specific case; he said that he was NOT the person to help me. He said that in MY case, sleep apnea is only one PART of the problem – and that I have a much bigger “insomnia” issue to deal with (to which I automatically agreed). At that point in time, I asked him about seeing a neurologist who specializes in sleep – and he told me he thought that was a good idea (which did not seem to surprise me). The pulmonologist does want to see me back in six weeks, though, so I will go to that appointment – and it appears I will keep him posted on any progress that I may make on MY end.

Again, I really would like to thank you for sharing with me that oftentimes, once the apneas (sleep apnea) are treated, insomnia usually resolves on its own. This is why I will look into the dental device for myself; also, you really helped me to try to “make sense” of all of this in my own mind – especially after what the pulmonologist told me. Thank you, also, for stating that “If the insomnia persists in a person with well-treated sleep apnea, then that is a good reason to reach out for additional help.” If I find that I need MORE help than what a dental device can provide, then I will certainly look into CBT – either with or without the help of a “sleep neurologist.”

I will keep you posted as to the results of my doctors’ appointments, MRI, use of a dental device, etc.


#4

Tamara,

Just to let you know, I will probably either keep seeing either my present pulmonologist OR see a different one altogether. I say this because I don’t know if my present one is the very BEST one to be handling my care (simply based on his comments and answers to my questions, as well as how he ended the visit with both me and my husband – with things simply “up in the air,” etc.). However, I don’t think it would be in my BEST interest to simply eliminate a pulmonologist altogether – especially after being diagnosed with a possibly life-threatening condition such as sleep apnea; also, wouldn’t a pulmonologist be the one who would refer me to any FUTURE sleep studies if, and when, they may be needed? I don’t know any OTHER type of doctor that would refer me for any other studies, even though this present pulmonologist already did say that he was NOT the best one to help me. I think I will seek out another pulmonologist (probably someone who my husband knows and he works with), and ask my present pulmonologist’s office for the original script for the initial sleep study (that my family doctor wrote me) – so I can provide another possible pulmonologist with that script. I will also comment on my present pulmonologist TO my family doctor when I see him tomorrow concerning my upper respiratory infection, and other things.


#5

Hi @Daisygirl

I’m glad I’ve been helpful in some way. Yours is a one-of-a-kind situation and there are many parts to your puzzle.

CBT can be useful for people who struggle with insomnia as well for those struggling with using CPAP, yes.

I can’t say how CBT helps people with concussion disorders as that’s more of a neurology concern and out of my scope of practice.

I would definitely see about getting a referral to a neurologist, as so many of the concerns regarding your concussions can be managed by this kind of specialist. A neuro who specializes in sleep would be a great find!

Your pulmonologist is expressing these things probably because his specialties are in the lungs and breathing disorders, but it’s clear you have additional concerns that complicate his role in finding the best treatment for your sleep apnea. I think what he’s told you is fair and honest and makes sense to me.

I wish you luck and hope you arrive at some answers and relief soon!


#6

Terrific information, Ms. Sellman. Thank you for taking the time to write.


#8

I have started using a cpap machine again after a 10+ years time frame. I’m surprised at how much quieter my machine is compared to the one I used in 2006. The drawback is that I’m still not seeing any change for the better. I also have RLS and possible narcolepsy. The doctor bumped up the compression with no noticeable improvement either. Since the cpap isn’t helping the ENT wanted to do a sleep study. However, the insurance company is denying the sleep study. If my benefit says I can have a in doctor sleep lab study then why are they denying the sleep study. I am still finding it difficult to drive to/from work because I fall asleep while driving. Im having too many near misses. I have found that munching on food while driving keeps me alert. But for obvious reasons I don’t want to continue to use that as my means to stay alert. Any suggestions? I’m close to chucking the cpap machine if the insurance company is denying the sleep study.