BCBS AL machine replacement

I wonder if there is anyone else using BCBS of Alabama or similar policy who had experience getting a replacement machine?

I've always been aware that my insurance replacement schedule will provide a replacement machine every 3 years.

But recently read the BCBS of AL Management of OSA Policy document. Quote :

Replacement Devices
Previously covered devices meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage to be replaced when the following criteria are met: (a repeat sleep study is not required)

• The equipment has suffered irreparable damage (cost more to repair than to replace) and has been in the home for 3 years or longer; OR
• The patient’s condition has changed and a different piece of equipment is determined to be medically necessary.

Replacement devices will not be covered for replacing functioning equipment with a newer more advanced model. (Compliance documentation is not required for replacement equipment.)
Proprietary Information of Blue Cross and Blue Shield of Alabama
Medical Policy #065
Replacement devices can be purchased items and are not subject to the rental only requirement. Replacement devices should be filed with modifier “RA” to indicate they are not the initial device but a replacement piece of equipment.

So it sounds like you can't replace a working machine even if its really old and you may benefit from the features of a newer advanced model

I wonder if and how this is enforced and if you didn't file a claim with "RA" for a replacement?

Uncle_Bob wrote:• The patient’s condition has changed and a different piece of equipment is determined to be medically necessary.

Would require the doc to speak up and the DME to file RA. Could be intolerant to a fixed pressure cpap.

Edit: I think their policy is pretty liberal and that most insurance policies are very similar. But hey 3 yrs is a pretty good deal and much better than Medicare.

Uncle_Bob wrote:I wonder if there is anyone else using BCBS of Alabama or similar policy who had experience getting a replacement machine?

I've always been aware that my insurance replacement schedule will provide a replacement machine every 3 years.

But recently read the BCBS of AL Management of OSA Policy document. Quote :

Replacement Devices
Previously covered devices meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage to be replaced when the following criteria are met: (a repeat sleep study is not required)

• The equipment has suffered irreparable damage (cost more to repair than to replace) and has been in the home for 3 years or longer; OR
• The patient’s condition has changed and a different piece of equipment is determined to be medically necessary.

Replacement devices will not be covered for replacing functioning equipment with a newer more advanced model. (Compliance documentation is not required for replacement equipment.)
Proprietary Information of Blue Cross and Blue Shield of Alabama
Medical Policy #065
Replacement devices can be purchased items and are not subject to the rental only requirement. Replacement devices should be filed with modifier “RA” to indicate they are not the initial device but a replacement piece of equipment.

So it sounds like you can't replace a working machine even if its really old and you may benefit from the features of a newer advanced model

I wonder if and how this is enforced and if you didn't file a claim with "RA" for a replacement?

Check with your DME. Shouldn't be a problem.

Uncle Bob - I too have BCBSAL, and was not real happy when I read the NEW amended replacement policy. Previously it was every three years - there was no proviso regarding irreparble damage. I will be interested to see how this works out for you since I am not at three years yet - but know that I will be wanting a new machine before mine gives up the ghost (features on new machines make them more practical for those of us who are active/pro-active in our therapy).

2flamingos wrote:and was not real happy when I read the NEW amended replacement policy. Previously it was every three years - there was no proviso regarding irreparble damage.

Will someone explain to me what is so bad about the policy?

What's GOOD about a policy that specifically excludes data machines and upgrades, only replacing your old machine if it is toast?
3 years only looks good if you ignore the rest of the description.

chunkyfrog wrote:What's GOOD about a policy that specifically excludes data machines and upgrades, only replacing your old machine if it is toast?
3 years only looks good if you ignore the rest of the description.

Where are you reading that at?

Uncle_Bob wrote:Replacement Devices
Previously covered devices meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage to be replaced when the following criteria are met: (a repeat sleep study is not required)

• The equipment has suffered irreparable damage (cost more to repair than to replace) and has been in the home for 3 years or longer; OR
• The patient’s condition has changed and a different piece of equipment is determined to be medically necessary.

I think they are relying on the DME & manufacturer to replace under warranty for any failure BEFORE the 3yrs mark. Is that what you are talking about?

Here in Michigan my BCBS, they will only replace your cpap if it breaks and is no longer serviceable, there is no three or five year replacement schedule. So if it is ten years old and they can semi fix it that's all they will do.

physicsbob wrote:Here in Michigan my BCBS, they will only replace your cpap if it breaks and is no longer serviceable, there is no three or five year replacement schedule. So if it is ten years old and they can semi fix it that's all they will do.

Now that's where you get the doc to change your script.

Or has it fallen off the nite stand yet? accidently of course

Under the previous BCBSAL policy, after three years you could get an upgrade replacement even if your existing machine was still working. Under the revision the only way to get a new machine (after the warranty is completely expired) is if the machine no longer works. so, under the old - if you got an upgrade after three or more years you could keep your old one as a back-up.