health insurance denies APAP.., What to do next?

[canyongirl]

I want an apap, need one medically.. oxford (my health insurance) denies the new machine, becuase they just paid off my cpap. if its medically necessary don't they have to provide it????

help.... what do i do now?

[Wulfman]

I want an apap, need one medically.. oxford (my health insurance) denies the new machine, becuase they just paid off my cpap. if its medically necessary don't they have to provide it????

help.... what do i do now?

No.
When was it determined that it was a "medical necessity"?......and by whom?......you or the doctor?

Sorry to sound blunt, but if you've had that machine for about as long as you've been on the forum.....you should have done something about exchanging it within the first month or two......BEFORE your insurance paid for it.

Do like many of the rest of us do.......if you WANT an APAP or whatever, buy it out-of-pocket and use the one you have as a backup. Most of these insurance providers will only replace a machine in 5 years.....if you're lucky......otherwise it's "once in a lifetime".......(could be the machine's or yours).


Den

[Rastaman]

My understanding is that insurance will pay for them every 5 years. But someone else might know more.

[canyongirl]

i do want the apapa, but my doctor descided (recently) to put me on appa.... so we went through the process. i have been fighting this for 5 months now....

after adjusting to cpap, i noticed my sleep wasn't always good each night, snoring,e tc. my doctor has been learning too. he wants to monitor my treatment.

i do want it, but it is medically necessary. it took me months to learn and understand that a data capable machine is really what should be provided in the first place.

i slept so great the first few months.. now im on track and doing ok.. my sleep should be better. My new sleep study proves i am having apneas and an apap is appropriate.

the DME was cheep and although my machine is good, it should be data capable. I fought with them for 2 months, and they won't change it because it costs them $. they buy the cheepest machine to meet their patients needs.

i didn't know then what i know now...

[jomac30]

I am in the same exact position as you. My doc prescribed apap, but the dme told me "it's our company policy not to provide apaps because they are more expensive. we will not give you an apap, we just finished paying for your cpap"
Are you in Massachusetts? Maybe we use the same dme.

Other dme's I talked to said if they had provided the original cpap and then the doc prescribed apap, they would have exchanged it for me.
I guess I got started with the wrong dme and am now in the process of getting a new dme-a little late but better for next time.

[dieselgal]

I think since it has been this long and the first machine is paid for you will probably not get another machine. I purchased my own M series auto with a/flex through cpap.com so now I have the original as a backup but my insurance would not have paid for it even if I got my Dr. to write me a script.

[Julie]

Your problem may have nothing at all to do with your machine. Many of us find that after a time on either C or Apap we discover that we have been mouth breathing (once asleep) though don't know it (can your wife tell you?) and therefore need to graduate to a full face mask (doesn't cover your face, but does add in your mouth along with your nose) so the air stays where it belongs rather than 'escaping' while you're asleep. That can definitely account for your unstable success, as can your machine having initially been set up for a pressure that's a bit on the low side - no sleep studies are perfect (to say the least!) and may need tweaking.

[sleepycarol]

Did you have a recent sleep study done in the last couple of weeks? If so they should be able to reset your machine to the new pressure.

Yes it would be nice if ALL machines were data capable. Unfortunately, they are not.

What are the medical reasons your doctor wants to switch you to an apap? I know you want the data, but let's face it the insurance companies could care less if we have the data available to us. Unless there is a sound medical documented reason that fits the insurance criteria you are probably out of luck.

I was lucky in that the sleep doctor prescribed me an APAP from the get go. My first DME gave me a M series Plus, but since my script specifically stated "smart cpap" I was able to switch my machine out (I had to switch DME's to get my apap though).

I recently purchased an older APAP from cpapauction for $50.00 including shipping to use as a back-up. It only had 250 hours on it and is like brand new. You might be better off purchasing one from there or craigslist.com out of pocket.

Good luck in your quest for an APAP.

[Fredman]

Funny that all machines are not data capable. When you are on meds for cholesterol, diabetes and others, blood work is routine every three months or so.

You think that Doctors and RT's would be concerned with getting real numbers to ensure appropriate treatment. Could you imagine how fast this would change if a class action law suit was brought against the manufacturers and doctors for not monitoring their patients appropriately?

It won't happen but I am surprised no one has tried to sue because treatment was not working and patient has been complaining and as a result of improper titration, sued for say an accident due to tiredness?

[lvwildcat]

They will only cover a new machine every 5 years. Was talking to a pulmonologist this week. I asked him why insurance companies have a fit when APAP is ordered. We all know the answer...BECAUSE OF THE COST!!! Why is EVERYTHING always come down to the almighty dollar????

[Snoredog]

well, if you have your script for the cpap and insurance has paid for your current plain jane machine you can:

Sell the cheapo machine on cpapauction or craigslist, use proceeds from it towards the auto you want from cpap.com.

[canyongirl]

ill try to sell and buy my apap... like i said i wish i knew then what i know nowor at leat right at the start of the therapy

i might try to up the pressure a little each week and see how i do.... my sleep study said pressures 10-14 were optimal...


thanks for all your help guys

this forum is so valuable

[sleeplessinaz]

Hi Canyongirl----I feel the same way that you do--that I know way more NOW than when I first started this CPAP stuff. It took me months to learn and understand that a data capable machine is really what should be provided in the first place--I was given the S8 Escape--which is a really nice machine but not capable of telling me any data about how I am doing. LUCKY for me---we had to change insurance companies and I got my Dr. to write a new script to ask for the S8 ELITE --I have a new DME as well so they have put the order in for me for the new machine. I shall keep my Escape for backups and traveling though.

I feel that I am doing well but on some nights I wake up or don't feel rested and that is what I need a new machine to tell me what happened on those nights so I will know what it is. The COMFORT GEL MASK is the same one I use too --but I had to get a "PETITE" size so it wouldn't leak on me---

Good luck in your quest---you may have to pay out of pocket or switch insurance companies when it is time to sign up at the end of the year for next year--
SIAZ

[CalicoskiesNC]

Here's something that worked for me. For many years I was carried on my dh's insurance even tho I had insurance available to me at my part time job. For 2008, I took insurance thru MY job, not his and this allowed me to get all new cpap equipment as I was treated like a new patient. Even tho I was BCBS with his employer and I'm BCBS my employer, my records did not transfer, I am treated like a new patient. I had to meet my $200 deductible, I used my rx from my dr and sleep study in 2005. I was able to get the new machine of my choice, I had asked my dr for a letter stating I was 100% compliant and that the new data capable machine would better suit my therapy. One month later, I had new APAP and I'm sleeping 1000times better, in fact I often sleep all night long without waking or moving! Good luck.

[OldLincoln]

I think since it has been this long and the first machine is paid for you will probably not get another machine. I purchased my own M series auto with a/flex through cpap.com so now I have the original as a backup but my insurance would not have paid for it even if I got my Dr. to write me a script.
_________________

Great idea and that's what I'll do if they refuse me. My unit is 9 months old and even though they've already paid more than it would have cost on cpap.com, I suspect they have a ways to go.


CPAPopedia Keywords Contained In This Post (Click For Definition): cpap.com, auto

Also...

I recently purchased an older APAP from cpapauction for $50.00 including shipping to use as a back-up. It only had 250 hours on it and is like brand new. You might be better off purchasing one from there or craigslist.com out of pocket.
_________________

I looked at cpapauction and wondered if the machines are really ok. Yours sounds like it is, what have others found?


CPAPopedia Keywords Contained In This Post (Click For Definition): cpap.com, auto