the long saga of getting a machine grrrr

man this sucks. went to the medical supplier today to get the papers (estimate and prescription) so i could fax them to my insurance company. i phoned them to see if they got the fax and found out it takes 24-48hrs for it to be on the system. i spoke to them about an apap and now i am told that the prescription has to say that an apap is medically necessary and the level of sleep apnea (which i think mine is moderate). the prescription does not say these things so now i have to get a new prescription. UGH i left a message at the sleep disorder place asking for an apt with the sleep specialist. i figure i keep phoning and relaying messages to him i might as well go in and talk to him. he might question the medically necessary part even though he okay'd the apap. i just feel very discouraged. i know it's never easy dealing with all these companies and high paid doctors but it's hard to keep pushing myself to try when i'm so tired. if i wasn"t afraid of losing my drivers licence i wouldn't even bother trying to get one right away. i would just wait till they call me. i just feel like i'm getting nowhere. just wanted to come vent my frustration with others who probably know where i'm coming from. thanks for reading this far.

SleepyMama, you're absolutely right that this sucks! Sadly, these sorts of bumps in the road are all to common. But patience and perseverance, and a "polite bulldog" attitude will go a long way to getting you what you need. Hang tough!

I have no idea how they work it in Canada, but my insurance in the US is an HMO. My doctor, who is willing to support me in all my self-advocacy for my health, wrote my Rx for exactly what I wanted... a ResMed S9 Auto and wrote medically necessary on the script. It was sent off and had to go under 'medical review'.... where upon the great HMO Wizard pronounced it DENIED! So... now he has submitted a new script for a straight ResMed S9 Elite with a set pressure and DAW on the script. This one, I think, has a much better chance of being approved. Or not. Have I mentioned how much I hate HMO's?????

In the meantime, I have my generic Rx for everything I want uploaded to cpap.com and cpapauction.com so I can get what I want, when I want it. But, since my insurance pays 100% with no co-pay, I am waiting this out a bit longer to see what they'll give me. Luckily my condition isn't that serious..... but it sure would be nice to sleep well soon and awaken refreshed w/some energy.

My doc's office staff is so wonderful..... I was told how happy they were about my assertiveness and advocacy for what I want. They totally believe in patients taking responsibility for their health issues. Such a breath of fresh air (no pun intended!).

But, since my insurance pays 100% with no co-pay, I am waiting this out a bit longer to see what they'll give me

I'd be interested to know 100% of WHAT? If the insruance pays by HCPC's code and pays the same amount no matter what machine you get, who cares if you get an autoset or a straight CPAP??? It is the rare insurance company that pays the actual "retail price" of DME. The only motiviation for not approving the autopap is if your HMO gets better rates from the required DME provider by ordering only lower cost items from them. And that doesn't address YOUR medical necessity.

This would have been worth an appeal. Appeals are no fun, believe me. I had to go a few rounds with Kaiser to get night braces for stretching for my daughter (she has mild CP) because she already had braces she wears in the day time for walking. Sheesh! But in the end, I won.

If your driver's license is at stake, I think the medical necessity is clear. You need an autoset that can respond to changing conditions like weight loss or gain or eating or drinking too late at night so that you can stay safely on the road. A straight CPAP won't do that.

Janknitz wrote: I'd be interested to know 100% of WHAT? If the insruance pays by HCPC's code and pays the same amount no matter what machine you get, who cares if you get an autoset or a straight CPAP??? It is the rare insurance company that pays the actual "retail price" of DME. The only motiviation for not approving the autopap is if your HMO gets better rates from the required DME provider by ordering only lower cost items from them. And that doesn't address YOUR medical necessity.

This would have been worth an appeal. Appeals are no fun, believe me. I had to go a few rounds with Kaiser to get night braces for stretching for my daughter (she has mild CP) because she already had braces she wears in the day time for walking. Sheesh! But in the end, I won.

If your driver's license is at stake, I think the medical necessity is clear. You need an autoset that can respond to changing conditions like weight loss or gain or eating or drinking too late at night so that you can stay safely on the road. A straight CPAP won't do that.

You may remember from my initial posts, my BCBS/FL Health Options has some wacko middleman called EMP who then delegates to a local DME to supply me. They (EMP) told me they don't approve APAPS at all...and so any scripts that they receive for those must go back to BCBS for medical review. EMP said that if BCBS did approve the apap, they would need to send that to another supplier. It is one of the craziest business models I've ever seen. This middleman plus a local DME just means more slices of the pie to be distributed. It is what it is.... HMO's have incredible power.

I suspect the problem was in my titration report. It didn't recommend auto settings at all as I was titrated nicely at a set pressure. My doctor recommended the autoset for patient's comfort. I doubt I would have won that appeal. So.... now on to straight cpap at a setting of 8.

I do very little driving as I work from home.

Sorry sleepymama...didn't mean to hijack your thread!! I'll start a new one once I have a decision and equipment!

what would be considered medically necessary reason to get an auto pap? i have anixety issues and panic attacks. i have allergies although not diagnosed that are seasonal.

i'm just wondering. the dr thought it was okay that i get an auto pap and changed the prescription however i don't know if it's as much medically necessary as it is a desire to have one. my weight fluctuates so i figured this would be the best way to make sure i'm getting adequate treatment for my OSA as well as the fact i'm terrified of wearing the masks. when i had my titration my anxiety was high but i took sleeping meds so i had no choice but to fall asleep. i did keep waking up gasping through my mouth. i noticed that when i opened my mouth to talk/cough the air would spew out of my mouth and cause me to choke (i guess that's what i'd call it).

i did keep waking up gasping through my mouth. i noticed that when i opened my mouth to talk/cough the air would spew out of my mouth and cause me to choke (i guess that's what i'd call it).

That's mouth leaking. If you are using a nasal mask or pillows, you MUST keep your mouth shut and lips sealed all night, otherwise the air coming in from the CPAP will just leak out your mouth and there won't be sufficient pressure to hold your airway open. That's why you see so many people talking about chin straps and taping--it's the only way they can keep their mouth sealed closed.

Some of us are lucky enough to be able to keep the mouth sealed naturally, or to learn (which is supposedly easy when the pressure is correct, but doesn't seem to be the experience of many here).

If you choose a nasal mask or nasal pillows, you're going to have to either work on keeping your lips sealed (if you keep your tongue on the roof of the mouth behind the front teeth it helps), or you will need something like a chin strap or tape to help.

ok sounds good i will have to do a search. at my first night sleepover i didn't do much mouth breathing however the titration i think i did more. my hubby frequently hears me coughing from our in the living room on a nightly basis. either that or grind my teeth, or actually gasp. wish i had my machine. i want to get used to it before i start back to work in sept. don't think i will have it by then. maybe i'll try that tennis ball trick.