CPAP prescription without sleep study?

[HappyNanaMO]

Hi, everyone --

This is my first post here. My S-I-L has had high blood pressure and severe snoring issues for the last decade or more. Over the years, his snoring has hit a few patches where it doesn't seam as bad, but his blood pressure is getting progressively worse and more difficult to managing, with ever-increasing dosages of meds. He believes his snoring has improved or isn't that bad, but my daughter and I have heard him at night, and while the snoring part would seem like mostly a noise issue, it's the gasping for air that leaves us alarmed and concerned.

He went in for a sleep study a few years ago and was told that his sleep apnea was mild and not enough to warrant a CPAP. I don't recall if that was a doctor's report or the insurance company's interpretation of the report. Meanwhile, his blood pressure medication is significantly higher than it was back then, and his blood pressure is impossible to control, with scary round-the-clock numbers. I feel like he is a walking time bomb as far as possible health consequences. I have read countless articles that convey the serious health risks of sleep apnea, especially as it relates to high blood pressure. I am fearful that his future is doomed if he doesn't get it under control. I have suggested that he simply ask his BP doc to simply write a prescription for a CPAP, so he can at least try it out and see if it helps or not, but he just keeps forgetting. Of course, that's just a hope on my part that it's as simple as that to get one.

So my question for all of you is: Does insurance require that you have a sleep study in order to get a CPAP? If not, did your doc simply write a prescription? What did you do if you didn't like the first one? Do you just keep getting additional prescriptions until you find the one that is Goldilocks-right for you? And does insurance pay for all of it, even without a sleep study? I would really love for him to try this out to see if it makes a difference for him, and I am optimistic, based on what I've read and what I know about his snoring/sleep apnea, that it will. But we just have to get it into his hands.

Thanks in advance!

Karen

[LSAT]

In almost all cases the insurance company will require a sleep study and a doctors prescription. If you are paying out of pocket, you may be able to find places to purchase without a prescription...including Craigslist. Be careful that you get a fully data capable machine if you go on your own. The problem is not whether or not you like the machine...the problems come with finding a mask that you are comfortable with. Insurance pays for 1 machine...1 humidifier and 1 mask. After that you are on your own.

[Pugsy]

Insurance is going to want proof of medical need....which means a sleep study stating that sleep apnea is the diagnosis along with most likely additional documentation stats from the sleep study. They won't pay for cpap without proof of medical need even if a doctor is willing to write a RX for cpap without sleep study results to back it up. Just because a doctor write a RX for anything doesn't mean insurance will pay for it.

Some doctors will write a RX without a sleep study and some won't....Probably most won't. Most online cpap vendors will require a RX but there are some that don't but a person has to be willing to foot the entire costs out of pocket.
There are ways to get a cpap machine without a RX...self diagnosis and self treat...it can be done but it takes dedication, education and a sincere desire to make it work.
Masks require a RX also...but again there are ways to obtain them without a RX.
If he is in denial about having sleep apnea he most likely won't want to do the work to self diagnose and/or self treat.

You might see if he will watch this video as it explains that sleep apnea is more than "just snoring".
https://www.youtube.com/watch?v=-gie2dh ... e=youtu.be

[HoseCrusher]

I found this very interesting...

https://www.amazon.com/Brevida-Nasal-Pi ... ds=brevida

Scroll down to Customer questions & answers.

"Do I need an Rx from my doctor to order the mask?

You do not need a prescription to order a mask."

I ordered one. Well see if I get it.

[tiredNorlando]

I had a sleep study done in 2011, dr said I had very mild apnea, wouldnt prescribe me a cpap but said if I gained more weight I would for sure have apnea bad enough for a machine.. he gave me a prescription for provent, which I used for years until they just didnt quite do the job.. was getting so tired during the day that I could barely stay awake at work..

Then I found this group and started asking questions and getting great answers. I just decided to get an auto cpap machine out of pocket on amazon for $400..with my ridiculous deductibles it would have cost me out of pocket close to $2000, so spending $400 on a machine as a trial and self diagnoses was cheaper and more practical! so far I am feeling better already, wish I would have done this 20 years ago!

This board has literally helped save my life

[chunkyfrog]

Some insurance plans are, by design, nearly useless.
If you wait for fhem to help, you may well die waiting.
Sometimes we have fo take matters into our own hands.
Many here have done that, successfully.
Some can afford/get useful insurance--the rest are, in a sense, "off the grid".

[Guest]

Insurance pays for 1 machine...1 humidifier and 1 mask. After that you are on your own.

IF your insurance paid for your equipment they will most certainly pay for any supplies needed to use this equipment. They will also cover a replacement cpap too as long as the user has passed the compliant stage and continues to benefit from using this equipment.

As always it is best to call your insurance directly to ask questions as some may differ.

He went in for a sleep study a few years ago and was told that his sleep apnea was mild and not enough to warrant a CPAP.

Could the apnea be worse now than it was then?

Over the years, his snoring has hit a few patches where it doesn't seam as bad, but his blood pressure is getting progressively worse and more difficult to managing, with ever-increasing dosages of meds.

The high BP could be an indication the apnea has indeed gotten worse.
When people who snore stop breathing we can think of the silence as breathing has improved because the snoring has stopped when in fact it is the breathing that has stopped.

[Guest]

my insurance wont answer any questions

i wrote my congressman to get them to tell me because they offer insurance to federal employees
still nothing from them

Make your request (to your Ins. Co.) in writing and CC your Ins. Commissioner.

Who is your Insurance with?

[Guest]

my insurance wont answer any questions

i wrote my congressman to get them to tell me because they offer insurance to federal employees
still nothing from them

Make your request (to your Ins. Co.) in writing and CC your Ins. Commissioner.

Who is your Insurance with?

bcbs

they are overseen by OPM not a state commissioner that i am aware -
i just wrote the top honcho at the insurance co

made many requests phone email and letter to the local office and the person the assigned to 'help' me when they got a letter from the congressman
their policy is not to tell anybody anything which is illegal as the policy is a contract and all parties have a right to know all the terms and conditions

IF you made your request in writing you have grounds to file an FOI complaint.

[RobertS975]

In almost all cases the insurance company will require a sleep study and a doctors prescription. If you are paying out of pocket, you may be able to find places to purchase without a prescription...including Craigslist. Be careful that you get a fully data capable machine if you go on your own. The problem is not whether or not you like the machine...the problems come with finding a mask that you are comfortable with. Insurance pays for 1 machine...1 humidifier and 1 mask. After that you are on your own.

=========

even medicrap pays for 1 machine every 5 years and humidifer every 6 months and masks every 6 months
and filters every couple weeks ....

Because someone can be approved for Medicare coverage, they must receive a variety of documentation including the pre-sleep study office encounter, the sleep study, and a relatively recent report that the patient is benefiting from their CPAP treatment, assuming they were on it prior to going on Medicare.

[robysue]

So my question for all of you is: Does insurance require that you have a sleep study in order to get a CPAP? If not, did your doc simply write a prescription? What did you do if you didn't like the first one? Do you just keep getting additional prescriptions until you find the one that is Goldilocks-right for you? And does insurance pay for all of it, even without a sleep study? I would really love for him to try this out to see if it makes a difference for him, and I am optimistic, based on what I've read and what I know about his snoring/sleep apnea, that it will. But we just have to get it into his hands.

Insurance companies vary a lot in terms of what documentation they need to authorize paying for a CPAP and supplies; how they actually pay for the CPAP and supplies; what documentation they require to continue paying for the CPAP; how often they are willing to pay for filters, masks, and hoses; and what conditions they'll pay for a replacement machine.

So you need to contact the insurance company and ask a lot of questions.

But in general, most insurance companies will demand some kind of documentation of compliance (usage) during the first 1-3 months in order for the insurance company to continue paying its share of the the cost of the machine. Some insurance companies will pay for 70-80% of the cost of the machine, if you've met your annual durable medical equipment deductible, which might be separate from the standard deductible. Other insurance companies may require a 50% copay for the cost of the machine. Supplies are similar: Some plans pay most (or all) of the cost of the filters, masks, and hoses once your annual deductible has been met; other plans are stingier.

Most insurance companies will also have an authorized replacement schedule for the filters, mask cushions, mask headgear, humidifier tanks, and hoses. Getting that authorized replacement schedule can take a bit of work. And your particular insurance might not be as generous as Medicare in terms of how often the supplies can be replaced.

What did you do if you didn't like the first one? Do you just keep getting additional prescriptions until you find the one that is Goldilocks-right for you?

Most new PAPers only get the chance to try out one PAP machine. The PAP machine is typically NOT changed unless the doctor orders a different kind of machine. Most insurance companies have one code for all CPAPs and APAPs, so a script that says "CPAP @10cm" can be filled by either a CPAP or an APAP. It's important to find out exactly which make and model of PAP a durable medical equipment provider (DME) intend to set you up with, particularly if insurance is paying for it---if insurance is being billed for the machine, the DME gets paid the same amount for a both a bottom of the line straight CPAP that records no efficacy data and a top of the line APAP. If you are paying out of pocket, the DME can charge different prices for different models of CPAPs.

For masks the situation is a bit different. A good doctor will write a generic script for "mask of the patient's preference" and the script is usually good for 1-5 years, depending on the state you reside in. If you are entitled to a new mask, you can chose any mask the DME carries or is willing to order for you without an additional script if the original script was for a mask of the patient's preference. Occasionally, however, a doctor will prescribe a specific type of mask (usually a full face mask) or even a specific model. In that case, you do need a different script to change masks.

Finally, most insurance companies will pay to have a defective machine repaired or replaced if the machine is no longer under warranty. They may insist on attempting to repair the machine first. Many insurance companies will authorize a brand new CPAP machine every 5 years or so. Some may need require that you have a new script. Some may require you to see a doctor before getting the new script. And a few may require that you undergo another sleep study. But increasingly insurance companies are trying to stretch out the replacement cycle, and some companies will only pay to replace a CPAP only if it is no longer working correctly and cannot be repaired, regardless of how old the PAP is. You have to contact your insurance company to find out what its rules are.