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Posted by seattlebill on June 07, 2006 at 08:42:48:
In Reply to: Kaiser Permanente: OSA Surgery? posted by Dash on June 06, 2006 at 15:39:46:
I can't believe that Kaiser won't cover PAP devices for OSA (although, I can believe that they won't cover corrective surgeries).
Like Sleepy says, you must first prove that you have OSA with a sleep study. Have a sleep doc prescribe a PAP or TAP dental device. Appeal the reimbursement for that device as many times as you need to to get it covered (this is doable, it is beyond question, the standard of care in the community...and denying standard of care leaves you open to further medical consequences that they will not want the liability for).
Then, demonstrate refractory medical issues to the use of a PAP device. "I just hate it" won't do the job. Go back, try different masks, etc... Problems like aerophagia (swallowing air),skin irritation, intolerance of high pressures, etc...can demonstrate that you have legitimate medical issues that make you refractory to PAP device therapy.
Then, you will need a referral to go to ENTs to try to correct the situation. During this time, you can look around and see if there are any folks performing an MMA in the Kaiser system. Whether or not you have any work done by a Kaiser ENT, you can then get an MMA consult by a sleep surgery specialist outside of the system who might say (or might not say) that an MMA will fix your OSA.
This is the hard part. This is where you need to appeal multiple times to the Kaiser Gods to show that 1)only an MMA will have the best chance to fix your OSA 2) that you've tried to be compliant but have been refractory to more common treatments (CPAP, BIPAP) for OSA 3) and that (presumably) no one in the in-network Kaiser system can do the MMA like a surgical center of excellence can...and that they are obligated by fiduciary duty to provide in-network coverage for this (presumably) out-of-network MMA surgery.
Yes, it is a long fight. But, it is winnable. First, you should drop the term "orthognathic" from your vocabulary. Although you can find providers this way that perform nearly identical procedures...the term implies that you are cosmetically correcting a bite problem. An elective, and usually not-covered surgery. What you want is a surgical procedure that will cure a condition that can involve many expensive medical conditions that Kaiser will need to cover and pay for over time. Tie everything to OSA, that is the only way to get any procedure paid for!
Bill
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