Insurance and getting an expensive machine?

[stickman]

Hey all. I am curious what others do when they want an expensive machine that will not be fully covered by insurance. I am looking at the S8 VPAP Auto 25 BiLevel Machine ($1300 at cpap.com). This is the one my uncle uses and he loves it. Unfortunately my insurer follows the medicare schedule. How do people get these machines without having to go completely out-of-pocket? Will the insurer at least pay their minimum and I pay the difference?

Thanks!

[Julie]

Can I sort of mention something without your taking it wrong in any way (I do mean well ? Cpap's are not like cars, the bigger and fancier the better necessarily. If you've just been prescribed a Cpap (or Apap) for moderate to severe apnea and given an average pressure setting of 8-12, it's very unlikely that you need the machine you're looking at (whether or not your uncle likes it), and spending anyone's money to get it could be overkill, overbuy or just an unnecessary expenditure. You'd do better to spend (if you can) on finding the ideal mask. If you have been told to get a Vpap/bilevel, that's another story I guess, and you might have to find an 'angel' if you can't afford the machine, but I thought it might be an idea to consider getting it if you don't need it.

[leejgbt]

Insurance reimbursement will be by the HCPCS code of E0470. There will be an allowable for this code with your insurance. If you use an in-netwrok provider they will be contractually obligated to accept the allowed price. If not you will pay higher copays and deductibles.

[Slinky]

THE BIG NUMBER ONE: you can NOT buy a bi-level, even from an online DME provider, UNLESS you have a script that specifies a bi-level.

A CPAP script will NOT get you a bi-level. MOST insurances insist you FAIL CPAP therapy before they will pay any towards a bi-level except under specific circumstances verified by your sleep doctor and PSG results.

[stickman]

MOST insurances insist you FAIL CPAP therapy before they will pay any towards a bi-level except under specific circumstances verified by your sleep doctor and PSG results.

Wow. It is ridiculous that a doctor would have to get permission from a pencil pusher. I guess it shouldn't be a surprise though lol.

[Slinky]

Yeah, well, you can't even buy a bi-level out of pocket from cpap.com or cpapauction.com w/a CPAP script, you MUST have a script for a bi-level to buy a bi-level, even out of pocket, from any reputable source. Take the issue up w/the FDA if you like.

[stickman]

Yeah, well, you can't even buy a bi-level out of pocket from cpap.com or cpapauction.com w/a CPAP script, you MUST have a script for a bi-level to buy a bi-level, even out of pocket, from any reputable source. Take the issue up w/the FDA if you like.

My point was that a trained doctor cannot write a prescription and have it 'filled' without some random lackey giving it their ok. IMO it's a pretty sad state of affairs.

[Muse-Inc]

...My point was that a trained doctor cannot write a prescription and have it 'filled' without some random lackey giving it their ok. IMO it's a pretty sad state of affairs.

Absolutely! My sleep doc says medical necessity for me to be using an APAP, my insurance says not needed -- tell me that's not practicing medicine without examining the patient. The damned ins doc reviews hundreds of requests a day..how much attn did my request get...yeah, you guessed it, just enough for him to refuse to OK the request as they just bought my CPAP 2.25 yrs earlier and didn't wanna spend more $. Insurance companies ration healthcare...they don't belong in healthcare, they suck profit out that could be used to deliver healthcare services & supplies. If I weren't living on unemployment, I'd have bought the ResMed AutoSet II months ago.

[elg5cats]

[quote="Muse-Inc"][quote="stickman"]... Insurance companies ration healthcare...quote]

Very True...........if you haven't watch SICKO, consider it!!!!! Sometimes whistle blowers from large corps have disclosed the huge financial kickbacks they received for denying approval for services......which ends people's lives sometimes!!!!!

elg5cats