Pre-Op Testing Complete & Insurance Preauthorized

My MMA Surgery is T-Minus 15 Days and Counting

Preauthorization Received - It's a Go

In just under eight (8) days my insurance company GEHA precertified my MMA surgery. I am amazed and proud of GEHA. Our prayers have been answered. My surgery is still set at Stanford University Hospital, Ambulatory Surgical Center on January 5th at 7:30 am. Check in is at 5:30 am which is great, since I am sure I will be finished sleeping by 3:00 or 4:00 am anyway. We will be staying in Palo Alto Jan. 3rd through Jan. 14th. We are driving our car both ways. It is 11 hours and 735 miles from Phoenix.

The only thing left to do, is enjoy Christimas and New Years with the family, pack and say my prayers for the doctors, nurses, hospital staff and a successful surgery. Amen

Pre-Op Testing Complete and Passed

I have completed the Pre-Operative Testing, CBC blood workup, EKG & Treadmill stress test and all is well.

Swallowing Concerns

I recently had some concerns about my upcoming MMA surgery and how it would affect some swallowing issues/choking issues I have had since my first soft tissue sleep apnea surgery. I sent Dr. Li several medical swallow test results which took place 1-2 years ago. I was afraid the new surgery might aggravate these issues. He informed me the surgery would not impact them. So no more worries. I am good to go. I would go tomorrow if I could.

Questions & Answers from the Doctors

My MMA Surgery is T-Minus 23 Days and Counting


Question and Answers from Doctors

We all come up with many questions especially when it concerns our health. I must paraphrase the questions I asked and the answers I received from Dr. Guilleminault and Dr. Li. I did not take many notes and as we all know us OSA patients don’t have the best memory, attention and focus.

Q: Will you be performing the surgery yourself or handing it off to an associate or medical student?

A: I do everything myself. I do have a long time assistant that helps me.

Note: This was an important question for me, because for my second disc surgery, my surgeon who did my first surgery, who I trusted and had complete confidence in, advised me the night before surgery that her associate would be doing the surgery, since she had to be at another hospital the morning of my surgery. I said no way and I wanted her there. Who knows who actually did this surgery, I certainly was not awake for it. Surgeons have to get their training somewhere!

Q: How does my jaw bone structure look (after looking at my x-rays)? Large, thin, strong, small, etc.?

A: Everything looks normal. Bone grafts not likely needed.

Note: I checked with my dentist (of 20 plus years) before leaving Phoenix and he told me the same thing. The last thing I want is for my surgeon to have to start removing bones from one part of my body and gluing them around my jaws.

Q: Are my central apneas (my recent studies show more central apneas than obstructive apneas) caused by my CPAP/BiPAP?

A: My central and obstructive apneas are caused by air not my brain (like true central apneas).

Q: What changes have you made in your surgical procedures over the past 1-2 years?

A: None.

Note: I asked this thinking he may have learned that certain past practices did not achieve the best results and that new avenues (ideas) resulted in better improvements. I suppose that this is good news for everyone that has had the surgery in the past couple of years.

Q: What has been your oldest MMA surgery patient?

A: 68 and also a 60 year old.

Q: How long should we plan on staying in town (since we are from out of town)?

A: 10 days.

Q: Based upon my x-rays do my prior disc fusion surgeries impact on my airway?

A: It does not appear that they have.

Q: Does OSA compromise my immune system?

A: Yes.

Q: Will MMA surgery improve my immune system?

A: I am not sure.

Q: My minimum oxygen saturation shown on my latest sleep study shows 93%. That doesn’t seem so bad. What do you think?

A: The reason it is higher than you think it ought to be is because it is while being treated with a CPAP. This is why I want to see your diagnostic studies.

Q: Can I judge the quality of my deep-restorative sleep by the frequency and length of my dreams?

A: No. You may also be having dreams that you do not remember.

Q: Will you be considering additional surgical procedures such as GA (Genioglossus Advancement) in addition to my MMA?

A: No. I do not perform GA’s unless my patient asks for that particular surgical procedure.

Note: I was concerned that once my surgeon got me on the operating table and opened me up that he might decide additional surgeries would be helpful. If possible, I wanted to know this in advance.

Q: Do you have an idea on how far you might be advancing my jaws?

A: 10-12 mm.

Q: Should I plan on donating blood for the surgery (hopefully in January) during this trip or isn't blood an issue? Or won't it keep?

A: Blood donation is based on the blood test that you will have at a later time and the likelihood is low that donation will be required.


Costs and Insurance

Back to my visit with Dr. Li. Molds were taken of my teeth. And my credit card…..no just kidding. I did receive a letter explaining the costs for the four procedures that will be billed. I don’t know if it is appropriate to say, but what the heck, I have been always been the type to tell it like it is: $45,000 (approximately). These procedures were broken out by procedure code, so it was easy for me to call my insurance company; give them the codes and they could tell me if they were customary and ordinary. This is important because I have a PPO and Dr. Li is an “out of network” provider. This means I am responsible for 25% of what is customary and ordinary and everything above that amount. Let’s just say I am very happy with the amounts that my insurance company set as customary and ordinary.

I asked my insurance company for it in writing and they refused. They did say our telephone conversation was recorded and could be accessed at a later time. I am not sure if I believe them. If I remember correctly, I think former President Nixon told the Justice Department the same thing. I should have recorded my call with the insurance company myself. It is important to note that you need to give the insurance company the zip code of where the procedure is going to be performed. The fee schedules differ according to where you are going to have the procedure performed.

The good news is that Stanford Medical Center Hospital is an “in network” provider for my insurance carrier so I will only have to pay 10% of certain services and a $100 admission co-pay. Are you ready for this? They could not give me the estimated costs for the hospital charges; however they said that hospital costs are typically twice the cost of the surgeon’s charges. That means the likely total charges for my MMA could be close to $150,000. Don’t forget the Anesthesiologist bill is separate from the surgeon’s and hospital bills. His quote for 5 hours was $3,200.


Diagnostic verses Titration Sleep Study

Most of us (considering MMA surgery) who have not received beneficial treatment with the CPAP/BiPAP treatment have had multiple sleep studies performed, hoping to find that ideal pressure setting and/or machine that will work. I learned from Dr. Li that the diagnostic sleep study is the type of study he needs to review prior to surgery. The diagnostic sleep study is the study that records your breathing patterns during sleep without utilizing a CPAP/BiPAP, thus recording your true apneas and hypopneas. This makes sense; unfortunately I never thought about that, otherwise I would have had a diagnostic sleep study performed just before coming to see Dr. Li.

My recommendation to those of you who are considering MMA surgery is to have a full night diagnostic sleep study done within the past year, especially if you have had any sinus or sleep apnea surgery performed since your last diagnostic study. I believe insurance companies hesitate on doing a full night diagnostic study and typically split diagnostic studies are done where the first half of the night is diagnostic and the second half is titration (where they try the different pressure levels).

My personal belief is that an all night diagnostic study should be done. Then based upon what they see, a second study is performed with the titrated pressure settings. I think this is especially important for someone like me who sleeps through the first 4 hours without wakening and then has very fragmented sleep during the later stages of sleep. You, of course, should ask your surgeon and sleep doctor.

Guess What....MMA Surgery on January 5th

My MMA Surgery is T-Minus 26 Days and Counting

Guess What?.................... I am having Surgery on January 5th, 2010.

I am flying high right now. The excitement is so great; I have almost forgotten my sleep apnea associated problems. I will elaborate below.

First Appointment: Stanford Sleep Medicine Center – Dr. Guilleminault

On December 7th we flew to San Jose and arrive at my first appointment of the day at Stanford Sleep Medicine Center (which is now located in Redwood City rather than at Stanford Medical Center in Stanford) for my appointment with Dr. Christian Guilleminault. We reviewed my sleep apnea history; he did a quick “look-see” of my throat and nose; we discussed my recent attempts to get my BiPAP to provide relief (air pressure setting of 18 cm); and I explained that nothing has changed. My symptoms today are the same as they have been since I was first diagnosed in March of 2006.

I looked over my list of 48 questions which I had been diligently preparing over the past 4 weeks, and fired away. I did have compassion on him; actually this list was for Dr. Li my surgeon; therefore I had the letter “G” placed beside only 19 questions. and I only asked Dr. G those questions. I don’t believe I have prepared so much for one interview, since my government days where I would prepare like this for a debriefing of a cooperating money laundering defendant who was about to turn on all of his co-defendants and tell all.

I will get to some of those specific questions later, but I would like to summarize Dr. G’s conclusions first. He restated (as he did back in January) that I was born with a small airway and a small jaw structure. The new news was: as I have gotten older the muscles and soft palate inside my mouth and airway has gotten relaxed and does not work as well as they use to. I have likely been snoring most of my life and snoring has a tendency to destroy nerve endings and the cells on the surface of your airway. This is something new I have never heard or read about. He elaborated further by stating that proper and correct breathing is dictated not just by an open and proper sized airway, but also by the communication between the brain stem and the airway muscles and nerves. This coordination and communication is very important for our breathing and inhalation/exhalation of oxygen.

He further stated, the soft palate surgeries I had, without a doubt, destroyed some of these nerve tissues and inhibited the required conductivity/communications. The bottom line is my disrupted and fragmented sleep is caused by both obstructed sleep apneas and the miscommunication or reduced communication of my breathing component of the autonomic nervous system.

Another factor bearing on this communication between my brain stem and muscles, etc. is the fact that I am 60 years old. We did not discuss that the age alone creates miscommunication but rather, any cells that were destroyed or damaged by snoring and/or the soft palate surgeries would not be restored as easily as if I were in my 20’s or 30’s. He went on to say that this is why many MMA surgeries are not 100% corrective.

Another factor that he believes may be affecting my airway is the two disc fusion surgeries I had had 10 and 15 years ago. If you do the math that is about the time I started having the depression symptoms (which are similar to OSA symptoms). There are two types of disc fusion surgeries. They are posterior and anterior. Anterior disc fusion surgeries (which I had) bring the surgeons work much closer to the airway. My neck surgeon was a great surgeon; however, there are always rewards and consequences when you chose to have surgeries.

Dr. G nor his “fellow” doctor who was assisting him would give me a recommendation to have the MMA surgery. They also would not say “don’t have the surgery.” Their recommendations were: Get a 35 degree bed cushion pillow which will elevate my head up above my body to offset gravity pulling on my soft tissue and closing my airway; losing some weight around my middle; and take two types of medication (Singulair and Flonaze) to help keep my airway open and possibly help with my chronic sinus infections.

Dr. G also pointed out the right side of my nose collapses when inhaling. That is something I never noticed and likely would never notice. This situation obviously affects my air intake especially at night while sleeping on my back. I will need to address that with my surgeon. My recollection from reading other blogs is that after MMA surgery, the nose tends to look wider (larger). I wonder how moving the jaws forward will affect the collapsibility of my nose.

Needless to say, I left Stanford and Dr. G feeling deflated. No pun intended. I have promised not to say this again, but I have to. I am an ex-marine. By the way we also say, “Once a Marine, always a Marine.” So we marched off to Dr. Li, who I was hoping and praying would see things in a better light.

Second Appointment: Sleep Apnea Surgery Center – Dr. Li

I grabbed my list of 48 questions. Dr. Li was going to get all 48 asked of him. We arrived at Dr. Li's office and his staff was very pleasant and welcoming. I turned over my two packets of exhibits containing sleep studies, lab reports, my sleep apnea history sheet (eighteen pages long), medical history including prior surgeries, current medicines, etc. Now that I look back on this appointment and the way I felt just before going in was like a felt before the big game (high school sports) or the start of a criminal trial where I would be presenting evidence or testifying against drug dealer, tax evader or money launderer.

I thought I had prepared the best I could. I had all my ducks in order. And now it was up to the jury. Dr. Li’s staff took ex-rays and prepared the video scope. Dr. Li came in….finally I am here… I can get the answer to my number one concern. Can I get a chance at fixing my problem or am I going to live the rest of my living life in hell? To my fellow believers forgive me, I do hope and pray on reaching Heaven and the Kingdom of God.

Well I can’t beat around the bush any longer. After all, this is not suppose to be a novel. Dr. Li’s words are still ringing in my ears. They were “John, I believe we can improve your sleep apnea 80-85% with this MMA surgery.” Other good words were: your age is not a factor; you are a robust 60 year old; as far as performing the surgery your age is not a factor (medical safety). My age really only decreases the percentage of success. At a younger age my improvement could be 90% plus.

From this point forward, I was flying high. I cannot describe how a felt then and how I feel now. I can imagine it is how prisoners of war feel when they see their captors hold their hands up in the air and their rescuers are coming through the front doors/gates. I know the surgery recovery will be tough. I know there are no promises. But with the results that others have achieved (thanks for your blogs & emails); the prayers of all of you; my trust in the Lord; and being in the hands of one of the best if not the best; I am confident that a good night’s sleep is in my future.

Dr. Li also stated that I may have some numbness that never goes away… for the rest of my life. My thoughts were because of my age. Things don’t repair as easily.

On our way out the door, I ran into two patients which had just undergone the MMA surgery. Ms. S. could not get her notebook and pen out fast enough after I told her of my good news and upcoming surgery. It is amazing how this difficult situation brings us so close to each other. The compassion, love, desire to help and encourage our brothers and sisters with OSA; and many other attributes seem to percolate from within us. It is not much different than how we were all drawn together after 9/11. I told Ms. S. I was 60 years old and a little concerned. Her notes to me read: Surgery 5 days ago; I’m 50; best thing I ever did; Dr. Li is the best; and here is my email address. Thanks Ms. S. By the way we have already exchange emails twice each.

Onward and Let’s Go

Needless to say, I have been going non-stop since returning from Stanford. This is the main reason why this posting is being made several days after my doctor’s appointments. My list of things to do:

Set Surgery Date…………………………....…...done
Pre-Operative Test – CBC blood test……...done
Pre-Operative Test – EKG…………………….done
Donuts and coffee………………………….......done
Pre-Operative Test – Stress Test.….appt. made
Arrange Stanford hotel & make reservations........done
Verify Insurance coverage & cost- surgeon.……....done
Verify Insurance coverage & cost - anesthesiologis......done
Verify Insurance coverage & cost -hospital.................done
Cinnamon roll and coffee…………………....done
Determine Insurance catastrophic protection (out of pocket costs)..done

Make appointment with for teeth cleaning..................done
Buy Magic Bullet Deluxe ($35 after$10 off at Costco......done
Make copies of medical directive,living will, etc.................pending
Share the good news with family & friends.....................done
Update blog…………………………………......done

I have decided to get this update posted now. I will follow up shortly with the Specific Questions and Answers from Dr. Guilleminault and Dr. Li. I also will include a topic regarding Diagnostic vs. Titration Sleep Studies and a section Costs and Insurance Issues.

Immune System Compromised

My MMA Surgery is T-Minus 31 Days and Counting

Immune System Compromised

On December 4, 2009 I received a call from my Allergy Doctor who provided me with the results of several blood tests which were taken recently. I have been having chronic allergy infections for the past five years. I have had eight sinus infections where I needed antibiotic treatment in the past two years. These immune system “immunoglobulins” blood test (see web site below) revealed my IgA antibodies are very low and practically non-existent. They further revealed my IgG antibodies are abundant (mid-range) but are not functioning as they should.

According to WebMD:
“IgA antibodies are found in areas of the body such the nose, breathing passages, digestive tract, ears, eyes, and vagina. IgA antibodies protect body surfaces that are exposed to outside foreign substances. This type of antibody is also found in saliva, tears, and blood. About 10% to 15% of the antibodies present in the body are IgA antibodies. A small number of people do not make IgA antibodies.”

“IgG antibodies are found in all body fluids. They are the smallest but most common antibody (75% to 80%) of all the antibodies in the body. IgG antibodies are very important in fighting bacterial and viral infections.”

http://www.webmd.com/a-to-z-guides/immunoglobulins

The question I have: Is my compromised immune system caused by sleep apnea and not obtaining enough deep restorative sleep?

And, with successful MMA surgery, will my immune system recover?

I would be very interested to hear from anyone who may have had this same situation and what were the results after surgery.

Few Notes of Interest

My MMA Surgery is T-Minus 36 Days and Counting

Pre-surgery Consultation

In six days I go to Stanford (Dec. 7th - this day will live in infamy). I will have a short consult with Dr. Guilleminault. I will then go see Dr. Li for my pre-surgery evaluation and consultation. I believe he will review my sleep study; conduct a physical exam; take xrays of my airway; take fiber optic imaging of my airway; discuss treatment options; and yes, discuss the costs.

Hopefully Dr. Li's findings will be that I am a good candidate for the surgery (remember I just turned 60) and that there is a very good chance of success. Based upon other blogs that I have read and the bloggers comments, I think I will be having Dr. Li leaning towards treating the apnea's by moving the jaws forward as much as possible even if it dramatically changes my looks. I told my wife, I can always grow a beard. Priest and Deacons in the Greek Orthodox Church are suppose to have beards anyways.

For those that are interested, the cost of the pre-surgery exam, consultation, and test is about $1,500. That will be a good test of my GEHA insurance coverage. I will likely pay something in the range of 25-50%.

I will write again upon my return from Stanford on September 8th.

No More Good Nights

Those few good nights have vanished as fast as they arrived (see my earlier blog). The only thing different in my sleeping routine has been the addition of a cool mist (with wick) humidifier set at 50% humidity. The brand name is Bionaire. If any one has comments about using a humidifier at night along with using a CPAP with humidifier, please let me know. I will try one more night with the room humidifier and then I will go a few nights with out it to see If a few good nights return.

Summary of the Best MMA Surgery Blogs

I have just started a summary of all the blogs on MMA Surgeries. I hope to post this like my Stages of Sleep document sometime between now and my surgery. Some of the sections of the summary will include: List of Blogs including location, date and surgeon; What to do before surgery; week by week expectations during recovery; what to eat and not to eat; etc.

Again any feedback you might have regarding this summary and what to include will be welcome.

So long for now. God Bless.