Sleep Apnea Treatment – What’s Covered by Insurers?

PORTLAND, Ore. – When it comes to nighttime, many people suffer from interrupted sleep due to Sleep Apnea. Medically, Apnea is an absence of inspiration (breathing) for at least 10 seconds. According to AllMed Healthcare Management (http://www.allmedmd.com/?prleap), a leading Independent Review Organization (IRO), the challenge with Sleep Apnea is that there are a variety of kinds which require different treatments.

Independent Review Organizations (IROs) play a central role in helping insurance companies and physicians determine the medically approved and covered treatment options for Sleep Apnea patients. Following is a list of the different types of Apnea that are currently identified by the medical community:

• Obstructive sleep apnea (OSA) is found in obese patients or patients with abnormal throat anatomy. OSA leads to multiple sleep-time arousals and excessive sleepiness during the day.
• Central sleep apnea (CSA) occurs when a patient’s brain fails to send the signals to the breathing muscles.
• Positional sleep apnea (PSA) is most common for patients that often sleep on their backs.

In addition to weight loss programs for obese patients, the recommended treatments for Sleep Apnea include:
• Air –The medically necessary treatment for clinically significant OSA is continuous positive airway pressure (CPAP). For some patients, bi-level positive airway pressure (BiPAP), which enables the positive pressures for inspiration and expiration to be set independently, may be recommended.
• Medication – CSA is treated with medication, medroxyprogesterone, which is a respiratory stimulant.
• Medical Equipment – PSA is treated by making back-sleeping uncomfortable for the patient. The usual treatment for this is a backpack vest with a soft ball inside.
• Surgery - Surgical treatment of OSA is controversial and is often combined with nasal cosmetic surgery that together holds less than a 50 percent success rate. Because weight loss is curative in most adult patients, routine sleep apnea surgery for this condition is not accepted medical practice.

As with any case, there are exceptions to the rules, such as for patients with pulmonary hypertension, hypertension or congestive heart failure, or for those that have completed a three-month clinical trial with a sleep specialist and have not responded to treatment. Independent Review Organizations (IROs) can help insurers simplify the process by identifying the medically accepted course of sleep apnea treatment on difficult cases. To find more information about the medical necessity review services offered by AllMed, visit http://www.allmedmd.com?prleap.

About AllMed:
AllMed reviews claims for issues of medical necessity, standard of care, experimental / investigational, hospital quality management, code unbundling, fraud, and other issues that affect healthcare decision-making.