Insurance Not Covering APAP Machines?

[jrfoster]

My doctor recommended that I switch from a CPAP to APAP. Ok, so he wrote a prescription for it, I called my DME to get one ordered and they said that it would cost me $500 with my CPAP trade in, and that Insurance would not cover any APAP. I was leasing the CPAP on a montjhly basis to check it out.

Is that true for all Insurance companies?

Jeff

[tmaiberger]

I just did the rental swap for an APAP. As far as I know, the "code" for APAP and CPAP are identical, so as far as the insurance company is concerned there is no difference. If your doctor wrote the prescription for the APAP and the DME is refusing to fill it, you might try to see if your insurance has any other preferred DME's in your area and transfer to them. One way to present it to your current DME is to say you know the code is identical so that is not a problem with the insurance company but with them and that if they looked at it closely they will realize that you will be "buying" supplies from them for basically the rest of your life and they will make their money off you and your insurance in the long run. Short term loss, long term gain.

Todd

[snoregirl]

I had a simliar experience however I never took a CPAP. Wanted APAP from the start.

My insurance considers an APAP to be deluxe equipment so can't get support from them to get the DME to give what the doc prescribed. You won't know this until you contact YOUR INSURANCE YOURSELF. Don't rely on the DME to tell you what your insurance covers. Call them and maybe you will be surprised. If they will cover it use them to pressure the DME or switch DME's.

If you have the problem I had, then it is a matter of getting the DME to give you what you are prescribed. The insurance company won't know the difference. Mine certainly didn't even after I appealed 3 levels of Insurance management. Code E0601 is CPAP. An APAP is a selftitrating CPAP still same code.

You can get the Remstar Auto for $709 with humidifier with your currernt CPAP prescription from CPAP.com.

If you haven't bought the CPAP (you say you have been renting) try the "I need the APAP as prescribed" I will be bringing your CPAP back on (end of the rental month). If you can't get the APAP for me at the same price (copay) I will have to go buy my own. And they might cave. They are losing a customer for their overpriced masks tubing......

I would never pay a DME $500 plus insurance copay for an APAP. You don't mention your level of copay but I am willing to bet it would exceed a total of $709 ($500 + some form of copay). That doesn't even include the irritation of having to make compliance for the insurance company, losing the brand new smart card when they swap it out to read and give you a used one, or fighting for the clinitians manual.......

Getting my APAP took three conversations and the third one was a charm. They kept calling me to say "We have your CPAP, we need to set up a time for you to come get it" I kept saying "Is it the APAP my doc presribed or a CPAP? On the third try they said, "Oh, I can get you one of those". I said "OK when will it be in?".

Good luck. Don't pay more to a local DME than you would by buying from CPAP.com. No tax, no shipping on a machine.

[jrgood27]

I would speak directly with your insurance. In my case, my doctor needed to provide them and the DME with a letter of medical necessity for the APAP and it was covered from the get go. Some insurances require you to try CPAP first and if it's not successful you can get an APAP.

[Guest]

My doctor recommended that I switch from a CPAP to APAP.

Is that true for all Insurance companies?

Jeff

It is and it isn't. Like most things with Insurance Companies - they muddy the water enough that hardly anyone can really understand.

A CPAP is covered under the universal billing code (called a HCPC code) E0601.

An AutoPAP does not have it's own special code, even though it obviously does a great deal more than a CPAP does. It is possible to get an Auto unit covered under the standard CPAP code. Much like it is possible to get a Ferrari covered as a 'car' the same way a Kia is a 'car'. Clearly 2 different classes of items under the same general heading.

Most all insurance companies have a clause though that will allow for any item without a specific HCPC code to be covered through a significantly more difficult process. This will generally be started by obtaining a Letter of Medical Neccessity (Called an LoMN for short) from your doctor. This is just a short note (often even written on a prescription pad) stating the following:
1) What you need (In this case, An Auto-Pap)
2) Why you need it in place of a CPAP (Something like - Have tried and failed on a CPAP)
3) How long you need it (For this - generally lifetime)

The DME company would then submit that LoMN along with the prescription for the autopap and a copy of the sleep study and other supporting documentation (CPAP trial reports, etc) to the Insurance Company.

That will often result in an insurance company approving a special authorization for an Auto-Pap under code E1399 (Miscellaneous).

[CollegeGirl]

Not everyone needs a letter of medical necessity, either. I didn't. I don't even have good insurance, and all I did was get my doctor to prescribe an APAP for me, take it into my DME (Apria) along with my CPAP, and say, "Okay, I'm trading this one for an APAP, my doc says I need it." They didn't even question me.

I didn't realize how lucky I was, especially given how obnoxious Apria can be.

But to reiterate: CALL your insurance company. If they say it's covered, go back to your DME and say "The insurance company says they DO cover it, and it's the same code as a CPAP. Now, are YOU going to give me what my doctor prescribed for the same price as the one I currently have, or do I have to go elsewhere?"

Good luck!

[Guest]

But to reiterate: CALL your insurance company. If they say it's covered, go back to your DME and say "The insurance company says they DO cover it, and it's the same code as a CPAP. Now, are YOU going to give me what my doctor prescribed for the same price as the one I currently have, or do I have to go elsewhere?"

Just one word of caution on this. Be very, very careful that you don't end up shooting yourself in the foot with this approach. You may or may not be supprised at just how often you get misleading or downright incorrect information from the insurance company when asking these sorts of questions, especially if you don't already know the answer and therefore know how to ask the question.
Here is a classic example. You call the insurance company and ask "Do you cover auto-titrating cpap units. Commonly called an Auto-Pap? Such as the Respironics M Series Autopap?" They may well look the item up and find out that Yes! That is a covered item!
This is great. What they can't look up without having all the details or in some cases without an actual claim is what all is required to qualify for that item. You may have to be on a cpap for 6 months and have failed. You may have needed to be on a bipap for 3 months. You may need to have a Letter of Medical Neccessity.
Insurance Companies are often a real nightmare to try and find your way through.
Very very rarely is a simple Yes/No question going to actually get accurate information with them.

[cpapjack]

Of course the DME will tell you that he insurance company won't cover an APAP. As other's have said, an APAP is billed under the same code as an APAP. I had the same thing happen with me with my ex-DME. I was initally renting a CPAP and then my Dr. wanted me to have an APAP. So I took the prescription to the DME and they said the same thing wand wanted to charge me $395. This is even after I called my insurance company toa ask them and they said if it's needed, they will cover. (I'm fortunate to be covered 100% for xPAP expenses) I told my DME this and they still wanted to charge me $395. So I called my insurance company again and got the names of a few other DME's in my area. I called one and explained to them my situation and they were more than happy and willing to help me out. I had my APAP machine 3 days later. Sounds like your DME is trying to rip you off, like so many other Brick and Mortar DME's. So my suggestion would be to take your prescription to a DME who is willing to accomodate you and who won't try to steal your money. Good luck !!

[Roundeye]

Hi folks,

I'm new here and have been sucking hose for about a month now. I am actually doing pretty well with it, having only one small problem. I hope to move from a standard CPAP (w/CFLEX) to a Auto just to see if my problem (feeling like I'm not getting enough air early morning right before I wake up) might be solved.

I expect to have to go through the same struggle that most others face to get it. My question is this: Because the insureance code is the same for CPAP and APAP, the DME will only get paid a set amount for either by the insureance. Don't the APAP machines cost the DME's more? If so, and I insist that they give me the APAP machine, doesn't that mean that I'm the one sticking it to them?

I must say that I have really learned alot from you folks! You have answered so many questions for me without even knowing it and I thank you greatly.

- Jeff

[cpapjack]

No, you're not sticking it to them. I think they can write it off.

[snoregirl]

Sticking it to them??? Please!!!

They are charging you double what you can buy it for from an online dealer at least. They are charging considerably more for tubing, masks etc .....$36 for a $10 hose for example and you worry about sticking it to the DME money making machine??

Go get your APAP. If you continue to use them for supplies they will still be rolling in your insurance company's cash.

[elliejose]

$36, are you kidding? I paid $59 for my $10 hose. NEVER again. I was in a hurry because kitty had smacked the hose and left enough holes to leak.
Tried teflon tape and it only held for awhile so called DME. I'll know better next time, tho. I made the mistake of calling from work and telling them I would be by after work to pick one up and DID NOT ask the price. I really wanted to tell them to keep it, but I already had my checkbook out writing the check when she told me the price. Couldn't believe it!! Live and Learn!!!

[Guest]

I expect to have to go through the same struggle that most others face to get it. My question is this: Because the insureance code is the same for CPAP and APAP, the DME will only get paid a set amount for either by the insureance. Don't the APAP machines cost the DME's more? If so, and I insist that they give me the APAP machine, doesn't that mean that I'm the one sticking it to them?

It depends on the actual model you are talking about and what rate your insurance company pays, really. If you have an insurance that pays $1300.00 for a setup, then the DME company may not have too much of a problem providing the more expensive APAP. If your insurance company is like mine and only pays around $800 they may not be so willing to provide an APAP without having you pitch in to help cover some of the cost. What it would come down to in my opinion is just talking to them. Asking them what they would be willing to work with you on. Treat 'em like a partner in your care and they may well supprise you with how far they are willing to go.

[Paulrp]

If you thing they are getting stuck if you make them swap the machine, you are wrong. Many people pay theses DME suppliers more for a machine through the co-pay on the 13 month rental than they would pay just to buy the equipment from the get go. If your insurance will reimburse you for the machine, turn in the rental and order one from cpap.com or the on-line retailer of your choice. If you are on Medicare, You are kinda stuck with a DME, but they have to give you what your doctor ordered. If you check on http://www.cpapauction.com, you will find that you can get a lightly used PR System One Auto with A Flex and Humidifier and case (No SD Card) for $300.00. the SD card can be had for 7.99 with a 3.00 rebate from staples.(Generic 2GB). That is less then my co-pay would be for a new one. I got one of these last week, and it is not the latest model, but the seller provides a 90 day warranty and I'll bet the balance of the PR two year warranty would be honored if something came up.

[Breathe Jimbo]

When I was renting an S8 Escape and wanted an S9 Elite for the detailed data and standard SD card, I read up here and then sent my DME a fax stating -- in no uncertain terms -- that I would be returning the S8 on Monday, my doctor agrees that I should have full data capability, they (the DME) have been very helpful and I would very much like to stay with them, would they be able to get me the S9 Elite, or would I need to go elsewhere, which I would prefer not to do because they have been very helpful and I would prefer to stay with them. Polite but firm -- "I am returning the S8," period. Worked like a charm. They did try to charge > $200 for six measly filters, but the insurance company knocked that WAY down.

Don't feel sorry for your DME; you need what you need.