CPAP VS. APAP and Insurance

[Lori Dawn]

I read somewhere on a thread that insurance will not cover an APAP? Does it matter if that's what the doctor prescribes specifically, and a specific brand of APAP after CPAP has failed? And what if it's after the 30-day "return" period?

[Wulfman]

I read somewhere on a thread that insurance will not cover an APAP? Does it matter if that's what the doctor prescribes specifically, and a specific brand of APAP after CPAP has failed? And what if it's after the 30-day "return" period?

It depends on your insurance provider. In reality, the cheapest straight-pressure CPAP and the highest-end (priced) Auto-CPAP (APAP) have exactly the same insurance billing code.......E0601. So, that's not necessarily true.

All of your other questions depend on various circumstances.

Some insurance providers DON'T or WON'T. Some DMEs DON'T or WON'T. Some doctors DON'T or WON'T.

Best advice is to ask your insurance provider.


Den

[EricinNC]

I read somewhere on a thread that insurance will not cover an APAP? Does it matter if that's what the doctor prescribes specifically, and a specific brand of APAP after CPAP has failed? And what if it's after the 30-day "return" period?

Lori, that is totally untrue. I have had two APAPs paid for by my health insurance and a third I bought myself. You have to have a doctor that is willing to advocate for you and that can be hard to find these days. It also helps to have a strong personality to push it thru yourself.

Other things that might help to get an APAP thru your insurance would be to tell your doctor that you sometimes drink at night (pushing your pressures up higher) or that you take sedative medications (prescription or OTC) whether they be anti-histamines or sedatives such as anxiety medications. Also, if your weight fluctuates a good amount, tell your doctor and DME/insurance and that will increase the chance of them giving you an APAP.

If all that fails, you can just get the script yourself, fax it to a reputable online CPAP dealer and buy it out of pocket. I bought my third one that way.

But it is absolutely untrue that insurance will not pay for an APAP. Some DME person or your insurance might have told you that, but its a bunch of baloney, these DMEs make less money off your insurance if they give you a nice APAP.

You just have to fight them.

Eric

[EricinNC]

The last APAP I got I had cheapo managed care health insurance from Bank of America. The first I got (the one that worked well), I had good health insurance, Blue Cross Blue Shield of NC from BOA. Much of it depends on your doctor. There are a few sleep doctors who simply dislike APAPs and if you get one of those, you wont get one unless he gives you the script and you can fax it to the Internet place yourself.

Just persist and you can get one.

ERic

[EricinNC]

I read somewhere on a thread that insurance will not cover an APAP? Does it matter if that's what the doctor prescribes specifically, and a specific brand of APAP after CPAP has failed? And what if it's after the 30-day "return" period?

Ive had two doctors prescribe me AutoPaps. All you have to do is push for it and ask for one and get one. Its not that hard to get.

Eric

[leejgbt]

As long as you start with an APAP then you are usually okay. While some physicians do not like to order APAP the vast majority do not mind. The trap is if you start with a straight CPAP and then decide to switch to APAP then your insurance will balk at paying for the APAP as both have the same billing code (E0601) so the APAP will be considered duplicate equipment.

[LinkC]

The trap is if you start with a straight CPAP and then decide to switch to APAP then your insurance will balk at paying for the APAP

That is exactly what I did, and there was no resistance whatsoever. My "new" 'script said APAP @ 14-20 and that's what I got. The "rent-to-own" contract started over with the APAP.

[DoriC]

The trap is if you start with a straight CPAP and then decide to switch to APAP then your insurance will balk at paying for the APAP

That is exactly what I did, and there was no resistance whatsoever. My "new" 'script said APAP @ 14-20 and that's what I got. The "rent-to-own" contract started over with the APAP.

It worked that way for us too. As soon as we realized that we were given a bare bones M Series Plus, we went to our Primary and he wrote an RX for the auto. The DME then gave us a hard time because he didn't prescribe a range of pressures so we had to go back and get a new script with the pressure range and then we received our new machine in 2 days. Of course this all took place within the first 30days.

[Lori Dawn]

I saw my GP yesterday, and he is supportive of my getting a data-capable machine. He said he would write a letter of medical necessity. He is not that experienced in treating SA, and I educated him on some of the information I have already recevied from this forum. He said that he thought this forum is an invaluable resource for me, and in turn, he could learn some things from me that would help him treat his other patients. He was very open, receptive and interested.

He said that he would write a letter of medical necessity and let me proof it to make sure it says exactly what I want/need it to say. I am going to see an ENT next Thursday, since that was his first suggestion. After I see the ENT, in the same office as my GP, the GP said he would write a letter. While I am there, I want to give him some written suggestions on what the letter should say to help it be approved by the insurance.

It's been two years since I got downgraded from the M Series Pro to the M Series Plus, and they say they will only pay for one machine every five years unless I get a letter of medical necessity. The M Series Pro was paid for by a previous insurance to the one I have now. So I am hoping some of you can help me give him some points for him to make in the letter that will make a good case for a new machine, even though the billing codes are the same, I am told.

I would also like it if he can say something in the letter that would call Blue Cross's attention to the fact that the DME talked me into trading in my perfectly good data-capable machine in for a dataless one so they could make my new insurance pay for it, unnecessarily, since the DME is a "preferred provider." How "preferred" would they be if they knew what they did to me, and I'm sure, to countless other unsuspecting new CPAP users? I am insured now by Highmark Blue Cross/Blue Shield of Texas.

I have been using the machine faithfully for almost a month and he believes I should have seen SOME improvement over that time, even if it was just a small improvement. He also said that he would be interested in following my progress and being able to see the numbers himself, so we, together can figure it all out.

Anybody experienced in dealing with insurance companies and what they will need to hear in order for them to approve the claim for a new PR System One Auto CPAP? I showed him a brochure on that machine and he agrees that it would be helpful to get that specific machine.

Here is a link to my original post which tells my story in detail, if that would be helpful:
viewtopic.php?f=1&t=62087&st=0&sk=t&sd=a

You-all have been so helpful already and I appreciate any help you can give me on this issue.

Thanks,

Lori Dawn

[Pugsy]

Need something to explain need for APAP as opposed to CPAP to create medical need. I nearly flunk English composition so I am not much help. Insurance company will likely balk at medical need for data only. Need something like no improvement after so and so length of time and APAP use offers more treatment options and accompanying data to evaluate therapy and might also not hurt to mention that it is cheaper than the more costly alternative, sleep study and then a new machine. APAPs are commonly used in situations where CPAP seems to be ineffective and they don't know why.

[Pugsy]

Question for you. I know you are trying to do this so insurance will pay. How much out of pocket will you have to pay with a new APAP? Have you done the math?

A simple CPAP prescription at cpap.com or the cpapauction will get you a new or near new machine and will get APAP machine. If your out of pocket dollars are a wash might also consider that option. Just depends on your finances and what your portion of the insurance might be. I know things are tight and sometimes paying out the co pay over time is all the choice we have.
Just a thought. Right now there is this one with no bids and starting at $240 and includes humidifier. Not many hours on it at all.
http://www.cpapauction.com/auction-list ... ifier.html

[leejgbt]

I am thrilled to see that insurance companies are recognizing that even though CPAP and APAP use the same HCPCS code that they are seeing in difference in toleration for many people. My company went with data capable APAP units as the only kind they provide in 2007 because it handled all patient needs short of a BIPAP. We did not change our pricing but instead insisted on better pricing from our venders. The only exception we have made is we will order a small, non-data capable, non auto CPAP that is battery driven for people who like to camp.