So with my BMI of 35 I need one comorbidity for my insurance to cover surgery. My question is... if I get diagnosed with sleep apnea... do I then need to use a breathing machine for some time before getting approval? I have BCBS of TX if that helps.

I have an appt with my PCP tomorrow to get a sleep study script... I'm assuming that's what I need to get the ball rolling. ☺️

Edited May 10, 20179 yr by CarmellaX

Significant amount of people who do a CPAP trial, if diagnosed with OSA and require one, cannot use it, for one reason or another.

If they decide you need a CPAP, do your best to use it. If you can sleep through the night with it, even better, if you can get wonderful nights of sleep.. that's awesome. OSA is very detrimental to organs like your heart and brain in the long term.

Some other comorbidities:

- Diabetes type 2 (need blood workup for this, sometimes fasting blood sugar/hbA1c)

- Liver disease (blood workup for this, and if high liver enzyme and other levels that suggest liver irritation prob ultrasound/MRE/MRI/biopsy), also metabolic syndrome, which tends to go hand in hand with progressive liver disease

- PCOS (I don't know much about this because only females get it to my knowledge, I do know my wife has it)

- Heart disease (high stage hypertension, or even hypotension.. and countless other factors I've not looked into because I only had high blood pressure and pulse)

There's some others in all likelihood, make sure you're checked for them all.. not merely to qualify insurance-wise, but because they sort of matter if you want to make changes to live a long life.

Thank you for the information. I do want to check to see if I have any of the cormorbilities listed in my insurance policy before I go through the self pay route. I guess my question is if it's typical for insurance to expect you to use a breathing machine to manage your sleep apnea and thus not cover the procedure because it's best managed that way. Hope my question makes sense.

34 minutes ago, CarmellaX said:

Thank you for the information. I do want to check to see if I have any of the cormorbilities listed in my insurance policy before I go through the self pay route. I guess my question is if it's typical for insurance to expect you to use a breathing machine to manage your sleep apnea and thus not cover the procedure because it's best managed that way. Hope my question makes sense.

Yep. If you can use it, you can.. and that's a very good thing if you are diagnosed with OSA and can tolerate a CPAP. But, many people (like myself) cannot tolerate the CPAP. Verify for the insurance that not tolerating a CPAP trial is condition for not covering you for WLS. It would make absolutely no sense because at least half the people who do the trials can't actually tolerate using the CPAP, so it should be expected. As long as the effort is there, logically, they should comply, but always CYA (cover your ass) and check anyways.

I cannot give my personal experience on the subject of private insurance because mine was covered by universal healthcare in Canada, and I never went through this process in the US (spent most of my life there).

Edited May 10, 20179 yr by PatientEleventyBillion

Although we have different insurance mines required not only me to have a formal sleep apnea diagnosis but I also had to have a Cpap machine and comply with a certain amount of time usage.

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5 minutes ago, erica2185 said:

Although we have different insurance mines required not only me to have a formal sleep apnea diagnosis but I also had to have a Cpap machine and comply with a certain amount of time usage.

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Are you able to tolerate a CPCP? And this requirement was regardless of whether or not you could tolerate the CPAP? Or was not-tolerating not an option?

And do they actually check the data on your machine to see if you're using the CPAP? I mean, I can see obvious caveats (if they don't check, no need to use it, they'd probably expect you to bring it in on surgery day, but they have anesthesiologists, and I'd just lie and say something like "last couple days I've had issues with it" so they'll be more aware of apneas during GA), but if they're control freaks, that really sucks.

That's why I'd definitely recommend OP CYA (cover their ass) and find out from their insurer.

Edited May 10, 20179 yr by PatientEleventyBillion

Are you able to tolerate a CPCP? And this requirement was regardless of whether or not you could tolerate the CPAP? Or was not-tolerating not an option?
And do they actually check the data on your machine to see if you're using the CPAP? I mean, I can see obvious caveats (if they don't check, no need to use it, they'd probably expect you to bring it in on surgery day, but they have anesthesiologists, and I'd just lie and say something like "last couple days I've had issues with it"), but if they're control freaks, that really sucks.

Yes mine checked in fact when I was not using it for 4 hrs a day the company threatened to take back my machine and report to insurance!! Needless to say I begin to comply now I'll be having surgery Monday.

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8 minutes ago, erica2185 said:

Yes mine checked in fact when I was not using it for 4 hrs a day the company threatened to take back my machine and report to insurance!! Needless to say I begin to comply now I'll be having surgery Monday.

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Ugh, I feel bad for you (unless your machine helps you a lot, in which case, I feel great for you ).. I wish you luck.

Edited May 10, 20179 yr by PatientEleventyBillion

Ok. Looks like I may have to mentally prepare to use a machine if I do in fact have sleep apnea. I wonder if I am expected to purchase it or if it's leased somehow? I would hate to spend money on these additional tests/ machines (my insurance does not cover every single medical expense) only to get denied by my insurance for bariatric surgery.

On 5/10/2017 at 4:34 PM, PatientEleventyBillion said:

Significant amount of people who do a CPAP trial, if diagnosed with OSA and require one, cannot use it, for one reason or another.

If they decide you need a CPAP, do your best to use it. If you can sleep through the night with it, even better, if you can get wonderful nights of sleep.. that's awesome. OSA is very detrimental to organs like your heart and brain in the long term.

Some other comorbidities:

- Diabetes type 2 (need blood workup for this, sometimes fasting blood sugar/hbA1c)

- Liver disease (blood workup for this, and if high liver enzyme and other levels that suggest liver irritation prob ultrasound/MRE/MRI/biopsy), also metabolic syndrome, which tends to go hand in hand with progressive liver disease

- PCOS (I don't know much about this because only females get it to my knowledge, I do know my wife has it)

- Heart disease (high stage hypertension, or even hypotension.. and countless other factors I've not looked into because I only had high blood pressure and pulse)

There's some others in all likelihood, make sure you're checked for them all.. not merely to qualify insurance-wise, but because they sort of matter if you want to make changes to live a long life.

I was one of those people who ended up with bruising and rashes, etc. on my face from CPAP machine use (tried every mask available and all bruised, leaked, etc). No tolerance whatsoever. My doctor referred me to a dentist who specializes in the oral device, which I have and am using. It's mainly better for someone with mild to moderate sleep apnea and may not be the best treatment for severe SA. If someone is intolerant to the CPAP machine, an oral device may be indicated, but that's up to the doctor of course. My husband had the surgery, which worked for a few years until he gained weight again. Now he's back on a CPAP. Surgery isn't foolproof or long-term, from what my husband was told. I imagine that if someone's insurance requires they use the CPAP machine a bit then it will likely fall into the time frame for doctor supervised diet program so I wouldn't think it would extend the waiting time. Just guesswork on that, of course.. I'm no expert by any stretch.

Edited May 15, 20179 yr by SummerShadow

57 minutes ago, SummerShadow said:

I was one of those people who ended up with bruising and rashes, etc. on my face from CPAP machine use (tried every mask available and all bruised, leaked, etc). No tolerance whatsoever. My doctor referred me to a dentist who specializes in the oral device, which I have and am using. It's mainly better for someone with mild to moderate sleep apnea and may not be the best treatment for severe SA. If someone is intolerant to the CPAP machine, an oral device may be indicated, but that's up to the doctor of course. My husband had the surgery, which worked for a few years until he gained weight again. Now he's back on a CPAP. Surgery isn't foolproof or long-term, from what my husband was told. I imagine that if someone's insurance requires they use the CPAP machine a bit then it will likely fall into the time frame for doctor supervised diet program so I wouldn't think it would extend the waiting time. Just guesswork on that, of course.. I'm no expert by any stretch.

Interesting info.

Regarding the surgery, it most certainly IS long term. What's even more important than the surgery being long term is long term discipline and habits. The surgery is not something meant to be a short stop-gap until you have something else done. When the stomach regains it's size, restriction will give way, and it's 100% up to the person to maintain the habits they were supposed to start.

2 hours ago, PatientEleventyBillion said:

Interesting info.

Regarding the surgery, it most certainly IS long term. What's even more important than the surgery being long term is long term discipline and habits. The surgery is not something meant to be a short stop-gap until you have something else done. When the stomach regains it's size, restriction will give way, and it's 100% up to the person to maintain the habits they were supposed to start.

I was remarking on the CPAP issue, not the surgery issue.