Sleep doc says APAP not medically necessary

[Autopapdude]

Bob, I think the consensus here is to get another doctor. If you as a patient think there is a chance that the apap is more beneficial to you than any other mode of therapy, you have a right to pursue that. I will join the other folks who say find a doctor who is more concerned with your needs than his ego or expertise.

[rjjayrt]

irregardless of you getting a prescription for an APAP, Its highly unlikely that your insurance would pay for your APAP retrospectfully (not sure of spelling). I say this because it was your decision to purchase the apap. Your insurance would rightfully ask why you did not attempt to use your insurance when you originally obtained the apap, apparently it wasn't medically necessary when you purchased it. Also your insurance would probably go back to the physician who originally wrote the RX not the physician who rights it now. Reason would be how does this physician who just wrote the RX know if it was medically necessary back when you purchased it. I agree that your doing better with the apap, I wish you'd of checked with your insurance back when you purchased rather than now, it probably would of saved you some money.

[Uncle_Bob]

I've accepted the fact that i will not get my $500 back from insurance for my Autoset machine and I'm not that annoyed at not getting the money back.
I'm just mostly glad i found this forum with all its helpful members. As it turns out along with all the help I've received here that $500 is turning out to be the best $500 I've ever spent.

Uncle Bob,

You can always ask your regular doctor to write a script for the APAP.
Karen

I wonder if my regular doc will write me one for a VPAP machine

Ya lost me somewhere in that story, Bob.

What machine(s) do you have?

Do you already have a CPAP AND an APAP?

Do you have your prescription (physical document)? (what does it say?)

You can purchase an APAP with a CPAP prescription from CPAP.COM.

Den

Initially they gave me a dumb F&P. The i found this forum and went back and got an S8 Elite II but could never get a pressure sweet spot.
I have Rx for CPAP and APAP, they have the OSA diagnostic code and my name etc, the APAP has my pressure range and both say "usage : lifetime"
I wish i knew i could have just bought a APAP with a CPAP Tx then i would not have had to go begging to the doctor for an APAP Rx.

Prior to that I have actually scanned in my CPAP Rx into the computer and started to Photoshop it into an APAP Rx. Naughty i know, but if it needed to be done

Did you talk to the insurance company or just the human resource person where you are employed? Did they know that you had a cpap that was less than a year old?

If your sleep doc has a vested interest in the DME you are probably out of luck. Did you buy your APAP from a DME or on-line? Will your insurance reimburse on-line purchases?

Yes i did talk to the HR dept, they clarified I can purchase on-line. They did know my machine was under a year old. I would never wish to line the pockets of my original DME , I purchased on line then I submitted the claim with the APAP Rx. But they required the letter also from the doc according to the rules.
I know for my health insurance at work that my company is self insured in that they assume all the risk and are the ones who pay out, blue cross just handle all the administration. Sometimes the rules can be changed but you really have to kick up a stink and its just not worth it IMO.

Your doctor's ego may be a big part of what I think you correctly figure is going to happen if you have a personal conversation with him, no matter how polite and deferential you are.

Anyyyywayyyy -- looks like you're already doing fine handling your treatment yourself, Bob! With an autopap, of all things! Imagine that!

Thanks rested gal
I've always tried to be polite, up until now I've had nothing but respect for doctors. My things have sure changed

I think you are right about the ego. My doctor gave me quite a bit of a lecture on how i need a doctor and that a doctor should not be replaced by a machine. According to him only big government and HMO's like APAPs because they are cheaper over the long run

When i returned for a check up with my Autoset reports in my hand he started to congratulate me on my vastly improved numbers, his tune changed completely and he even mentioned how great it was that we were working together.

[Uncle_Bob]

irregardless of you getting a prescription for an APAP, Its highly unlikely that your insurance would pay for your APAP retrospectfully (not sure of spelling). I say this because it was your decision to purchase the apap. Your insurance would rightfully ask why you did not attempt to use your insurance when you originally obtained the apap, apparently it wasn't medically necessary when you purchased it. Also your insurance would probably go back to the physician who originally wrote the RX not the physician who rights it now. Reason would be how does this physician who just wrote the RX know if it was medically necessary back when you purchased it. I agree that your doing better with the apap, I wish you'd of checked with your insurance back when you purchased rather than now, it probably would of saved you some money.

I hear what you are saying and that's another way of looking at it. However i did go back to the doctor and get him to write an Rx for APAP before i purchased the machine. Much the same way as i went to him at first, got my study, got my Rx for CPAP and then purchased a machine.

If he agreed to write an Rx for APAP and has seen the positive results with my therapy while on the APAP I'm still wondering what the problem is with the letter.

[sleepycarol]

This is strictly my opinion, so take it for what it is worth.

I think everyone should receive an autopap, even if the doctor feels you would do better on straight cpap with a single pressure. It should be fully data capable. Lots of things can change in a few years time. I feel that one should be able to have access to the data, regardless if they are getting a copy from the DME or downloading it at home. I know many do not care about the data -- but when things go south it is far better to be able to see what is going on than not.

In talking with my son-in-law he mentioned that his mom is snoring again and his dad has about had it and ready to move to couch. She is on a machine with a full face mask. I offered to download her data and yep, she has the M series Plus. No way of telling what is going on. She is on a pressure of 16 (if I remember correctly) and has used her machine for a little over 2 years. Joe says she uses it nightly but is getting discouraged. Hummmm, and then they wonder why so many fail treatment!!!! I have thought about letting her try my extra machine, but Joe's dad smokes cigars -- the big stinking kind that reek. I do not want my machine to reek of his cigar smoke due to my asthma. They are struggling to make ends meet so I feel for her as purchasing another machine is out of the question for now. If anyone has ideas, I am open to suggestions for her.

[JRI]

Get a new doctor! When I first started down this road I did a lot of research, mostly on this board. I picked up a lot of information that I used in making my case with my doctor. Long story short... He had me set up with a CPAP and a DME. I did not like the DME and did not feel the machine he specified was in my best interest. I specified the equipment I wanted, he wrote the script and I took it to the DME of my choice.

I would be highly suspect of any doctor who could or would not articulate to me a reason he dismisses any course of treatment. I get annoyed when a technician won't reveal the results of a test (I paid for) to me but I can undestand and accept the protocol. When a doctor does the same thing I say it's time for a new doctor.

[mattman]

Most of the suggestions posted here are pretty good and I think you've got most of what you were looking for.

I do just want to offer one thing to consider:

From having worked on the paperwork side of things for far too long I have a good idea of what kind of paperwork any doctor will have to sign when an APAP is being submitted to an insurance company.

The "Medical Neccessity" means that the doctor is going to have to sign a document attesting to the fact that a CPAP has been tried and will not treat the symptoms of sleep apnea.

That means he/she is putting his/her license on the line that all tests and attempts at treatment prove that a CPAP is not effective regardless of how you "feel" or if you agree/disagree.

Like it or not, that does put doctors into some pretty risky territory and while I hate the situation I can't always fault the doctors for being reluctant to put themselves into extremely serious legal waters (Potential Federal jail time, forfeiture of business/house, fines, etc etc).

There is of course no way for anyone to know if that's the case here - I just wanted to toss that out there for consideration.

[jnk]

If APAP and CPAP are the same insurance code, as far as insurance is concerned, they are two of the exact same machine, aren't they?

Most of the suggestions posted here are pretty good and I think you've got most of what you were looking for.

I do just want to offer one thing to consider:

From having worked on the paperwork side of things for far too long I have a good idea of what kind of paperwork any doctor will have to sign when an APAP is being submitted to an insurance company.

The "Medical Neccessity" means that the doctor is going to have to sign a document attesting to the fact that a CPAP has been tried and will not treat the symptoms of sleep apnea.

That means he/she is putting his/her license on the line that all tests and attempts at treatment prove that a CPAP is not effective regardless of how you "feel" or if you agree/disagree.

Like it or not, that does put doctors into some pretty risky territory and while I hate the situation I can't always fault the doctors for being reluctant to put themselves into extremely serious legal waters (Potential Federal jail time, forfeiture of business/house, fines, etc etc).

There is of course no way for anyone to know if that's the case here - I just wanted to toss that out there for consideration.

[sleepycarol]

Then why do some docs prescribe apaps from the get go? It seems that everyone would have to "fail" cpap in order to get an apap. As far as the doctor signing my apap was a medical necessity it wasn't on the script that I am aware of.

[rjjayrt]

I believe everyone should have a cadillac, it has all the options, its built safer but it costs more. As with everything else in life there are choices, It is hoped that you have a good sleep doc or DME and they together with you make a good choice. Apaps are not necessary for everyone but a fully data capable machine is a must....Just my opinion...

[jnk]

I believe everyone should have a cadillac, it has all the options, its built safer but it costs more. As with everything else in life there are choices, It is hoped that you have a good sleep doc or DME and they together with you make a good choice. Apaps are not necessary for everyone but a fully data capable machine is a must....Just my opinion...

In the old days APAPS were expensive. Ain't so no more. Every CPAP sold should also have the ability to auto-titrate, whether it is used every night that way or not. It will save money in the long run, since overnight lab stays can be reserved for those who really need one. That is why making sure every CPAP sold can also auto-titrate will actually save everyone money in the long run and help to lessen the congestion in scheduling NPSGs. It is simple math. The choice is obvious. To me, anyway.

In other words, for the sake of simple economics, I would argue that APAPs ARE necessary for everyone, even if they run it most every night in simple CPAP mode. That way the sleep doc can arrange to get a 90% or 95% pressure number whenever he wants one, for free, without having to schedule an NPSG. The DMEs and labs might lose a little money in the short term, but everyone wins long term.

APAPS are dirt cheap. Not Cadillacs. The Cadillac analogy is old school. Kinda like arguing that automatic transmissions should be reserved for those who really NEED one, when now an automatic transmission is considered a base feature, standard and included with little or no extra cost in all cars.

jeff

[KengEsq]

irregardless of you getting a prescription for an APAP, Its highly unlikely that your insurance would pay for your APAP retrospectfully (not sure of spelling). I say this because it was your decision to purchase the apap. Your insurance would rightfully ask why you did not attempt to use your insurance when you originally obtained the apap, apparently it wasn't medically necessary when you purchased it. Also your insurance would probably go back to the physician who originally wrote the RX not the physician who rights it now. Reason would be how does this physician who just wrote the RX know if it was medically necessary back when you purchased it. I agree that your doing better with the apap, I wish you'd of checked with your insurance back when you purchased rather than now, it probably would of saved you some money.

I hear what you are saying and that's another way of looking at it. However i did go back to the doctor and get him to write an Rx for APAP before i purchased the machine. Much the same way as i went to him at first, got my study, got my Rx for CPAP and then purchased a machine.

If he agreed to write an Rx for APAP and has seen the positive results with my therapy while on the APAP I'm still wondering what the problem is with the letter.

Hi Uncle Bob,

My experience with CPAP was similar to yours. My sleep doctor had no problems changing my script to an APAP and life has been great since I started using my APAP. Great numbers and compliance. I armed myself with everything I could get my hands on for my meeting with my sleep doctor to use to convince him to change me from CPAP to APAP but discovered I did not need it. He readily wrote the new script and my BC/BS paid for it all without a problem.

[carbonman]

The DMEs and labs might lose a little money in the short term, but everyone wins long term. jeff

WOW ....whatever you're smok'n, popp'n or shoot'n......
sure wish you'd share w/your friends.

Are you hang'n w/Timothy???

[jnk]

The DMEs and labs might lose a little money in the short term, but everyone wins long term. jeff

WOW ....whatever you're smok'n, popp'n or shoot'n......
sure wish you'd share w/your friends.

Are you hang'n w/Timothy???

I don't need drugs. I'm just naturally goofy!

Thing is, I truly, honestly, believe that giving patients APAP will help sleep labs and DMEs in the long run financially.

Anything that increases a patient's chance of being successful increases the likelihood of making money off of that patient. APAPs increase that likelihood.

Many labs are booked up six months or more in advance. Repeat customers are not necessary there in most cases.

For every patient that has a good experience with PAP therapy, several of their family members and friends become more likely to see that sleep doctor or DME. Sleep docs and DMEs should take note and provided APAPs to help that word-of-mouth free advertising.

But the smart sleep docs and DMEs already know that.

All seven of them.



jeff

[Irene P.]

Uncle Bob, I would suggest you sit down and have a face-to-face talk with your doctor. It worked for me. I tried for a couple of months to get copies of my sleep report and prescription by phone calls and letters. I don't know if they ever reached my doctor himself. Finally, I made an appointment, had a friendly chat with him, and got everything I wanted and more. He was very responsive. It can't hurt.