Primera Sleep Apnea Qualification Question
I have Premera and they have specific requirements for sleep apnea to count as my co-morbidity. They say my AHI needs to be above 30 or my RDI has to be 16 - 30. My AHI is 27 so, that's out but, my RDI is 36. Technically I guess I don't qualify since I don't fall into that range but, would I be denied because of that? I would think I qualify but, I'm not sure and I called Premera and the person I talked to didn't seem to be able to figure it out either.
Thanks for any input!
If you have a link to the specific document that mentions this, I'd be happy to try to help you figure it out. It's crazy they require your AHI to be over 30 to count as a comorbidity -- sleep apnea is typically diagnosed at an AHI over 15, or over 5 if you have other health effects of sleep apnea like excessive daytime sleepiness or hypertension. It also doesn't make any sense to put a cap on how high your RDI can be. The higher it is, the most disordered your breathing is during sleep. Those two rules also make no sense together because RDI is always higher than AHI, but since when do insurance companies actually understand what they're writing rules about, right? That's why I'm curious to read their actual regulations.
I couldn't get to the specific Premera page that I wanted but, here's the requirements on the bariatric surgery source webpage which is verbatim what they sent me as the requirements. I called Premera and even the rep I talked to couldn't give me an answer.
http://www.bariatric-surgery-source.com/premera-blue-cross-weight-loss-surgery-requirements.html
Wow, that's pretty much just how you put it in the original post. That makes no sense at all. It LOOKS like they're trying to say moderate or severe apnea qualifies, but it seems to be written by somebody who doesn't understand what AHI and RDI are and what the difference is. Is there anyone you can escalate the question to at Premera?
I called Premera and the rep I talked to had no idea. She even went so far as to Google AHI and RDI while I was on the phone...I think I'll keep digging until I get a definitive answer. It seems almost like an asinine statement designed to give them an out so they can reject the surgery...I don't know, maybe I'm just paranoid. You're right, though, it doesn't make sense and I do wonder if the person who wrote it doesn't quite get it.
Well, at least you'll get a final answer when your doc submits for insurance approval! The way it's written now, they approve for severe apnea and mild-moderate apnea, but not for moderate-severe apnea that falls in between. It makes no sense at all.
maybe they actually DO know what they are writing,in that their research has shown them that MOSt ppl fall into the moderate-severe category and by writing the plan this way they can avoid having to pay for surgery for the largest number of subscribers.
