Smart ring at home testing for sleep apnea

[dataq1]

I doubt insurance would pay for a CPAP based on the test from the ring, but that was the rationale the doctor gave me for ordering the ring test.

I can't speak for the hundreds of commercial insurances, including Medicare Advantage plans (which are actually commercial insurance plans), BUT traditional Medicare first and foremost requires a physician's statement of medical necessity. If the Doctor says it's medically necessary and the doctor maintains documentation that the AHI is above threshold level.......

Medicare will pay for CPAP machine. The sleep test (however it is conducted) has to meet the Dr's criteria to declare a machine to be medical necessity.

[Ray4852]

lot of senior citizens are over the barrel with medicare. I know. you have to meet their guidelines to get them to pay. I had a problem with medicare with my oxygen problem. my doctor warned me my medical problem was related to my sleep apnea. my O2 levels were border line. no way medicare will pay for a portable oxygen concentrator. my reply. write me out a prescription for a concentrator. I will buy my own. if I had a problem with my cpap. I will pay that too. life is to short to play politics with these people. cpap cost is cheap. concentrator cost a little more but over the life of one. its cheap too. people think nothing of paying 80 grand for a truck to carry your fanny around or pay 5 grand for a weeks vacation. I'm 70 year old. I can't take my money with me. if I don't spend it somebody will take it.

[robysue1]

What is sleep apnea? The cessation of breathing.

Hypopneas are a significant part of obstructive sleep apnea and RERAs are a significant part of the more broadly defined sleep disordered breathing, and neither of these involves a "breathing cessation".

How does the body react to a cessation of breathing?

Blood oxygen levels begin to drop within seconds of breathing cessation.
But the body may also react by being aroused - that is the brain is "activated"
Some take the position that this brain activation is caused by falling oxygen levels.

Hypopneas and RERAs, which are respiratory events that are indeed part of OSA and the more broadly defined sleep disordered breathing involve restrictions on the free flow of air into the lungs caused by a partial collapse of the airway or an unstable airway that is in danger of collapsing. And they can lead to respiratory related arousals.

And arousals related to sleep disordered breathing events can happen before a drop in O2 can be measured. Hence the AASM's definition of hypopnea that allows for a hypopnea to be scored on a PSG if there is a 30% drop in airflow and an associated arousal---even if there is no corresponding drop in O2.

IMO, if the scope of the testing is limited to cessation of breathing, oxygen desaturation is a good indicator.

Looking at nothing but O2 desaturation data may be useful in telling you that you've got a problem with obstructive apneas and hypopneas that do have associated desaturations. But it will not accurately point to a real problem with sleep apnea if the problem is due to hypopneas with arousal and RERAs. You need flow data and EEG data in addition to O2 to definitively rule out obstructive sleep apnea as a source of bad sleep.

In other words, to answer the OP's question: Lots of O2 desats recorded by a smart ring do imply there is likely real problem with sleep apnea. But the lack of O2 desats does not, by itself, rule out sleep apnea as a potential cause for poor sleep.

And to go just a bit further: If there are lots of O2 desats recorded by a smart ring, the desats themselves are not enough to distinguish whether the problem might be obstructive sleep apnea or central sleep apnea. And that distinction is critical for the prescribing an appropriate way of treating the problem.

[robysue1]

I doubt insurance would pay for a CPAP based on the test from the ring, but that was the rationale the doctor gave me for ordering the ring test.

I can't speak for the hundreds of commercial insurances, including Medicare Advantage plans (which are actually commercial insurance plans), BUT traditional Medicare first and foremost requires a physician's statement of medical necessity. If the Doctor says it's medically necessary and the doctor maintains documentation that the AHI is above threshold level.......

The problem is: Medicare is not going to accept documentation that the AHI > 5 based solely on a nonmedical device (i.e. a smart ring) saying there are lots of desats during a four hour period during the night.

Medicare will pay for CPAP machine. The sleep test (however it is conducted) has to meet the Dr's criteria to declare a machine to be medical necessity.

Medicare will pay for the CPAP only if they approve of the kind of sleep test AND if the AHI is computed using the AASM optional rule for scoring hypopneas---and that optional rule is more strict than the recommended rule.

AASM recommended rule: Score a hypopnea if there is at least a 30% reduction of flow for at least 10 seconds AND one or both of the following occurs: There is an associated EEG arousal or there is an associated O2 desat that is at least 3% or both.

AASM optional rule (designed to placate Medicare): Score a hypopnea if there is at least a 30% reduction of flow for at least 10 second AND there is an associated O2 desat that is at least 4%.

The importance of these rules cannot be underestimated for some people: My two diagnostic sleep tests show an AHI of 23 and 19 with hypopneas scored under the now "recommended rule", but they show an AHI = 3.5 when hypopneas are scored under the "optional" (Medicare) rule. In other words, once I go on Medicare, I lose my insurance coverage for new xPAP machines and CPAP supplies even though I have been fully compliant (in terms of usage) since September 24, 2010 and have been clearly benefiting from the use of the machine since roughly July or August 2011.

Sources: A transition to the American Academy of Sleep Medicine–recommended hypopnea definition in adults: initiatives of the Hypopnea Scoring Rule Task Force

Does Medicare cover CPAP and other PAP therapy for sleep apnea?

What do AHI, RERA, Arousal and RDI mean?

Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA)

[Miss Emerita]

Bbridge, the Wellue O2 ring that you linked to doesn't seem to measure peripheral arterial tone (PAT). PAT home tests can do a fairly good job of measuring AHI. What I don't know is whether the ring version of a PAT test is as good as the versions that you strap onto your wrist like a watch.

When you took your test, did you stop using your machine for a few days before the test?

Do you know exactly what the test results are?

Also, if the doctor had looked at your machine's data, what would he have seen? What AHI do you usually have when you're using your machine?

Unless you lost a lot of weight or made some other big change in your life, it's unlikely your sleep apnea just went away. If the doctor says you don't need PAP, based on this home test, I hope you will ask for a sleep study in a sleep lab.

[dataq1]

In other words, once I go on Medicare, I lose my insurance coverage for new xPAP machines and CPAP supplies even though I have been fully compliant (in terms of usage) since September 24, 2010 and have been clearly benefiting from the use of the machine since roughly July or August 2011.

Did Medicare tell you this (that you will lose coverage for new machines and supplies)

My one and only sleep study was done in 2002. (twenty years ago)
Since that time I have been compliant and my Dr says I've benefited from using CPAP and supplies. He sends a notice of medical necessity to the DME every year.
Ten years ago I transitioned to Medicare, with no new study was required.
In the past ten years Medicare has covered two new machines and countless supplies. - no new sleep study required - ONLY the Dr's notification to the DME that it is a medical necessity.

I switched DMEs about three years ago, and they wanted a new sleep study. I asked them what they wanted it for, they could only say "their records". They allowed that a sleep study done 19 years ago was just fine, as long as they had the Dr's NMN statements on an annual basis.

I asked if the Dr or the DME sends a sleep study or the notifications to Medicare, and they said no the only thing they or the DRs sends is a claim. They keep a sleep study and NMN (notification of medical necessity) in the their (DMEs) files.

Of course, your mileage may vary.

[robysue1]

In other words, once I go on Medicare, I lose my insurance coverage for new xPAP machines and CPAP supplies even though I have been fully compliant (in terms of usage) since September 24, 2010 and have been clearly benefiting from the use of the machine since roughly July or August 2011.

Did Medicare tell you this (that you will lose coverage for new machines and supplies)

While I have not (yet) talked to an actual person at Medicare, I have been perusing the official medicare websites, as well as other reliable sources.

The following link is from the Centers for Medicare & Medicaid Services and is on an official website of the United States government:
Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA)

It clearly states

Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility.

And as long as they're going to insist that the hypopneas have at least a 4% oxygen desat, they'll be able to use my two diagnostic PSGs done in facility-based sleep labs to say that my AHI = 3.5 and hence I don't qualify for an xPAP.

The problem is simple: Both of my diagnostic sleep studies were done using what was then the AASM "alternate" definition of a hypopnea---that "alternate" definition is a variation of what is now the AASM "recommended" definition of a hypopnea. And on my sleep tests, the hypopneas were specifically scored as "hypopneas with arousal". So from the language on Medicare's own official webpages, those hypopneas don't "count" and my AHI is only 3.5 instead of 23.5. Hence, in Medicare's eyes, I don't have OSA at all.

My one and only sleep study was done in 2002. (twenty years ago)
Since that time I have been compliant and my Dr says I've benefited from using CPAP and supplies. He sends a notice of medical necessity to the DME every year.
Ten years ago I transitioned to Medicare, with no new study was required.

And back on your 2002 sleep study, I bet the hypopneas on your sleep study were scored using the criteria that Medicare still uses---i.e. I bet all of your hypopneas did have at least a 4% O2 desat associated with them.

As I said before, the hypopneas scored on my original sleep test in 2010 did not have at least a 4% O2 desat associated with them. But they did have EEG arousals associated with them. And that meant my RDI = 23.5 and my employer provided health insurance had no trouble using that diagnostic sleep test to justify setting me up with a CPAP and when "I failed CPAP" due to severe aerophagia issues, my insurance had no trouble using that diagnostic sleep test to justify setting me up with a bi-level machine. And they've had no trouble paying their (lousy) 50% of the costs of my supplies since then. And they gladly paid for a replacement bi-level in 2016 without requiring a new sleep test, and they're ready to pay for another machine to replace the bi-level I got back in 2016.

The second diagnostic sleep test I had in 2013 was to investigate other sleep issues, primarily related to sleep maintenance insomnia that was a huge recurring issue for me between 2010 and 2015. In the spring & summer of 2013, the insomnia monster once again moved into my bedroom and was destroying my sleep. The sleep doc at the time wanted to see what my sleep would look like both with and without bilevel support in order to see whether the sleep maintenance insomnia was noticeably worse without the xPAP. The data from the second diagnostic sleep test and the follow-up titration test demonstrated that the sleep maintenance problems were about the same with or without xPAP and that they were actually worse than my subjective reporting of the insomnia. That was followed up by an Actigraph test over the course of a couple of weeks which confirmed really awful sleep maintenance problems and eventually led to a script for Belsomra, which I continued to take until the pandemic caused problems with getting the script renewed. This second sleep test also used what was then still called the AASM "alternate" definition for hypopnea, and all my hypopneas on that sleep test were scored as "hypopneas with arousal" (the RDI = 19.something). None of the hypopneas scored on the 2013 diagnostic test had a O2 desat of at least a 4% associated with them, and the Medicare defined AHI was again something like 3.5.

I will add that back in 2010-2013, I did have at least one sleep doc tell me that if I had been on Medicare, then Medicare would not have covered the xPAP equipment without a long fight involving the Medicare appeal process and that at the end of the day, the appeal might or might not have been granted. All of this is why I am leery about what's likely to happen when I do become eligible for Medicare next summer.

[dataq1]

The following link is from the Centers for Medicare & Medicaid Services and is on an official website of the United States government:
Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA)

It clearly states

Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility.

The most significant line in that quote is this:

The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility.

My wife had a home study as did my brother all within the past 13 months. Each of them had Medicare cover the cost of not only the the test itself but CPAP equipment and supplies. (in two different CMS regions)

So, Medicare may still say that home or mobile facility tests will not be accepted, apparently they actually do.

To repeat myself: What is controlling is whether the Doctor will endorse your certificate of medical necessity. If he will not sign a certificate (for whatever his reasons), it wont make any difference where or who performed the test.

IMO, if your doctor will sign your MN, you are worried unnecessarily.

[robysue1]

To repeat myself: What is controlling is whether the Doctor will endorse your certificate of medical necessity. If he will not sign a certificate (for whatever his reasons), it wont make any difference where or who performed the test.

IMO, if your doctor will sign your MN, you are worried unnecessarily.

My brand new sleep doctor has had no issue with signing a certificate of medical necessity for my insurance company and PR. I have a brand new sleep doc because the old one retired shortly before covid hit, things have been going well, and I hadn't needed to find a new sleep doc until the PR recall stuff happened and PR's email and patient portal site indicated that I had to have a new script sent in order to have my machines replaced under recall. The brand new guy took one look at the multipage 3 month summary report + detailed data in an Encore Pro print out and asked me how I was feeling and how I was doing. He also had noted that my medical history indicated severe insomnia problems and that I had been on Belsomra for several years, so he also asked about that stuff. He then said he'd sign the paperwork that PR needed as well as start the paperwork ball rolling to get me a new machine through my insurance. And told me to come back in a year unless something happens with my sleep and I think I need to talk to a sleep doc about it.

However, when I brought up Medicare, the new sleep doc did tell me he is not at all sure whether Medicare will cover my xPAP stuff once I go on Medicare since my original sleep test was scored with the wrong kind of hypopneas. And that's specifically why I have opted to have my current insurance pay 50% for a new machine rather than wait and gamble on Medicare denying coverage instead of paying 80% for a new machine next summer, regardless of what PR ever decides to do in terms of replacing my two PR machines that are under recall. The fact that I started seeing bits of foam in my DreamStation's humidifier tank in October 2022 just made it clearer that I needed to not wait any longer on PR and that it was foolish to wait until going on Medicare to see if they'd pay 80% of the cost of a new machine.

And for what it is worth, back around 2016 or 2017, my MIL did have a doctor sign a certificate of medical necessity for a BiPAP due to problems related to treating her COPD after she was taken by ambulance from her nursing home to a local ER in severe respiratory distress, and she came home with a trial machine that was helping her. But Medicare insisted that in order to pay for the machine she would have to have a sleep test, and the sleep test showed no apnea or minor apnea. Medicare refused to pay for the machine and the DME took it away because my MIL was too stubborn to simply pay for one out-of-pocket. I finally had to negotiate with her nursing home to get them to allow her to use my DreamStation BiPAP Auto while I went back to using my System One BiPAP Auto. I finally got my DreamStation back after my MIL died in 2019.

My point is that you and your wife have been lucky when it comes to Medicare. And some of us aren't so lucky. Bean counters are going to count beans, and somebody always winds up having coverage denied for something that ought to be covered. Given what happened to my MIL, I'd rather plan as if Medicare ain't going to cover anything and be pleasantly surprised if/when they do instead of being rudely surprised that they won't pay for things I think they ought to and then spending a long time wrangling with them through the appeals process only to have coverage still denied. Best to be prepared for the worst case scenario in my opinion.

[Wondering1]

You might call your DME and ask if they actually send your sleep study to Medicare, mine does not.

Otherwise suit yourself.

[bbridge_GA]

This is a follow-up to my original post. I found all of my old sleep lab studies from 2006-2015 including one from Mayo in Jacksonville. I also had the SD card with data from the past year of almost 100% compliance. He ordered me a new machine, the same Airsense 10 APAP. When I met with his nurse at a follow-up a few months later, she said that they weren't using the company with the smart ring for at home testing anymore. Apparently, the company was supposed to be sending out a strap to measure chest movement and respiratory effort along with the ring in order to meet insurance requirements....and they weren't.