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Adventures in Sleep

Ultimate responsibility?

Published August 1, 2014 8:52 AM by Penny Mehaffey

Problem: A patient was diagnosed with sleep apnea 5 years ago and has been treated with CPAP since. At his office visit this year he complains of poor sleep and a return of symptoms of OSA. He has gained 60 pounds and has other lung problems as well. 

His doctor orders a new sleep study since it's been 5 years. Said sleep study is promptly denied by the strategically aimed, absolute and total no-care comprehensive major government services coverage plan he has. Default request of HST denied promptly as well.  

It seems that all approvals for this scenario hinge on the download data over the last 5 years. No problem, it's a reasonable request. Patient can't locate the smart card, thinks it was lost a while back during home renovations, but, that he has not been using it for a while since "it got mold in it ." Ok, let's check with the DME, who is unable to provide documentation, and says that's most likely because patient did not keep their follow up appointments.

This is a nightmare.  You have a patient who legitimately needs something but can't prove they were ever compliant, an equipment provider who can offer no evidence either way and a hardline payor who absolutely will not approve any testing without the requested information. 

There are missing links here all along the way and it's very difficult for the person stuck in the middle who is trying to obtain what is now needed for the patient.  Did ultimate responsibility lie with the patient?  Were the rules this strict 5 years ago? Did the DME do all they should to follow up? And should it even matter? If you consider just the new symptoms only wouldn't he qualify for at the least an HST? 

Where do you think the ultimate responsibility lies?

4 comments

Adventures in Sleep : Ultimate responsibility?

September 27, 2014 6:02 PM

Why would another sleep study even be considered? I'm with Maria as well this patient needs an auto trial. At the very least do an overnight O2 study which costs the patient nothing. It sounds like this patient hasn't been compliant with CPAP. He doesn't need his SD card for a download. Any card can be used. Do you expect the DME company to do a stake out and hunt the patient down? I'm pretty sure that is considered harassment.We can't help the patient if they do not return our calls or show up for their appointments. This is not an uncommon scenario.

Aimee , Homecare - RRT/RCP September 7, 2014 3:04 AM
Clyde NC

I like the response of Marla, thinking from the perspective of an RT.  There are problems associated with the download.  What if the machine which is 5 years old is not capable of holding any data, what are the chances of the software and hardware malfunction, esp., when the machine is not in use and given that it is moldy tells me that there was some water damage to it.  But, apart from the above mentioned, the responsibility lies with the physician to show the necessity of a diagnostic sleep study to re-establish the diagnosis and look for any other sleep disorders missed if any, 5 years ago.  Any insurance and Medicare would approve a repeat diagnostic study after 5 years, esp., if the patient is symptomatic.

Chakri August 26, 2014 7:34 PM

Both major cpap manufacturers, Resmed and Respironics, have the ability to insert a smartcard and download existing up to at least 2 years data on the cards. The rules have been getting stricter about compliance over the last 5 years.

Suggestion would be to loan patient an Autopap with pressure range set at 4-25cmH2O for a 4 week trial pressure test for data download to determine optimum pressure/show need for sleep study..

Marla, Respiratory - RCP August 6, 2014 11:34 PM
Sacramento CA

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    Adventures in Sleep
    Occupation: Sleep technicians
    Setting: Various sleep facilities
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