DME won't submit to insurance for approval

[lazer]

45yr old male. Diagnosed with "mild sleep apnea" and heavy snoring. Also have been struggling with depression, anxiety, and never feeling rested during the morning or day. Waking up throughout the nights. Had an in home sleep study done beginning of this year through NovaSom per my family physician. He is supportive in me getting an APAP and feels getting me a better quality of sleep could likely fix much of my problems, however, we have hit a road block with the local DME. They won't even submit a claim to my insurance because they say that my "score" doesn't meet the criteria required. My doctor even wrote for per-authorization to my insurance back in February and the insurance finally replied March 27th with a per-authorization for 1 month rental but the DME still wouldn't go anywhere with this and continued to refuse me. I have been back in touch with my Doctor and Insurance and have supposedly got the insurance company to re-authorize the service for the end of this month through end of May. My doctor tells me once he gets this authorization he will talk the DME into at least submitting it. I have also contacted NovaSom and authorized them to fax me my sleep study which I now have.

Questions: What numbers am I looking for on it to even get an idea from you folks if I have any chance of getting the insurance to actually kick in on this? And I'm assuming if the DME does go with this 1 month rental this time, is that going to be enough time to produce any results or data to send back to the insurance for a permanent solution? I'm paid into my deductible so I am really pushing for this to be covered but if it isn't, I've priced out a somewhat affordable solution here at CPAP.com being the IntelliPAP AutoAdjust Travel CPAP, Heated Humidifier, and ADAM Circuit Nasal Pillow CPAP mask at around $620 shipped. Any advice on that selection?

Thanks, Ron

[chunkyfrog]

Keep trying; keep reminding the doc how bad you feel,
and get a different DME if you can-(they don't sound very helpful.)
You are already doing about what I would be doing.
As for numbers: do you mean AHI?
Insurance companies may have different requirements for coverage,
but if you can convince your primary care physician that your symptoms are severe enough,
he can go to bat for you in a marginal situation.

[Blindrage]

That makes no sense at all. If the insurance company has already preauthorize the CPAP then this is the equivalent of the DME saying they do not want the insurance company's money.

Time to find a new DME.

[Gerryk]

Go find a different DME. These days even Walgreens will handle the equipment. Sounds like this is a DME that also does sleep studies and wants you to come in for one of their sleep studies. You have your Dr and insurance approval, go get the equipment some place else.

[chunkyfrog]

Insurance is giving the OK for a one month trial--probably on a full-data APAP.
DME doesn't want to touch this!
They know how hard it will be to sell you a brick after using a good machine.
Go to another DME!

[GumbyCT]

That makes no sense at all. If the insurance company has already preauthorize the CPAP then this is the equivalent of the DME saying they do not want the insurance company's money.

Time to find a new DME.

BINGO

Troubles now = Troubles later

Look for a machine on Craigslist but before you do read & learn here how to check a machine and be sure to get one that records data.
http://www.statewidelist.com/

[Pugsy]

I have a used (minimal) Adams Circuit mask system that you can have. Only has the green (large) pillows.
If you like the idea of nasal pillow mask...going inexpensive route.

EBay has mask parts where you can build your own mask...for significantly less than online price if you shop smart..Especially for the Swift FX.

Or consider this new one. $85 Aloha...inexpensive (cough) by cpap mask standards but I just tried it last night and it is a definite keeper.
https://www.cpap.com/productpage/devilb ... -mask.html

I can pretty much guarantee that you would like the Aloha and Swift FX a whole lot better than the Adams.
But I will gift you the Adams...it is doing nothing in my parts box except gathering dust.

I don't know what "numbers" your DME is looking for nor which numbers that your insurance company needs to justify a diagnosis of OSA. Your home study? What numbers did it come up with ? Less than 10 AHI? Less than 10 makes it hard to swing a OSA diagnosis but sometimes other criteria is thrown in there to make the diagnosis. Home studies are limited and sometimes the data just isn't there to satisfy insurance. There must be something lacking in the reports that the DME has available to them to have them refuse to submit to insurance. Normally DMEs will do whatever it takes to get a sale.

Going without insurance involvement......
Personally...if it were me...I would go with a Respironics PR System Auto Cpap with AFlex (APAP)....the data available is a bit more comprehensive than on the Intellipap Auto (APAP) and the price isn't all that much more. The Intellipap lacks a bit of data that I find rather important.
You can get one of the new PR S1 APAPs in the heated hose 60 series for $649..that includes humidifier.
I can help you with the software.for the reports.
The slightly older model PR S1 APAP was $619 last I looked (includes humidifier).

Whatever you decide...you can have the Adams circuit if you want it. I think all the pieces are there...headgear, mask hose and the green nasal pillows. Price is right...Free.

And along with the others....find a different DME...something just isn't right with this one. Not normal to turn away business.

[GumbyCT]

Going without insurance involvement......
Personally...if it were me...I would go with a Respironics PR System Auto Cpap with AFlex (APAP)....the data available is a bit more comprehensive than on the Intellipap Auto (APAP) and the price isn't all that much more. The Intellipap lacks a bit of data that I find rather important.

Not to mention if you need help there are more people who know how the Respironics works.

Not knocking the Intellipap at all. People do like them and they are prob a very good choice for an experienced person who won't have tons of questions, that's all.

But hey, if you come across a deal on any machine grab it.

[lazer]

Thanks for the help and suggestions thus far everyone and special thanks to Pugsy for your offer regarding the mask - I'll certainly keep this in mind. Just a little more background on my situation. My sleep study was as I mentioned "In home" for 3 days actually the first week of this new year. When the results were sent to my doctor, he noted to me that I have "mild" sleep apnea and snore a lot. He was first suggesting "positional therapy" along with a 20lb weight loss which I accomplished the later but the "positional therapy" - tennis balls in a sock pinned to the center of my back (I guess this was to prevent me going on my back at night and thus reduce snoring??) anyhow, that didn't work in the past so I didn't even try it. I ended up waking myself up more during the nights when rolling onto my back so this plan defeated the purpose. As mentioned, I have also suffered depression, anxiety, and insomnia for the past 6+ years and have been and still am on quite a cocktail of depression and anxiety meds which help somewhat with that but never seem to help with the sleep quality which actually seems worse when my depression and anxiety are in check with the meds. Aproximately four years ago I did have an "in lab" sleep study done which proved next to useless other than show I never hit what they call "REM" sleep. I know looking back that night it took forever to get to sleep in that strange environment with electrodes stuck to every part of my body and when I did finally get to sleep it seemed like it was time to get up. Based on the recent in home study my doctor does agree there is merit and reasoning there to still pursue CPAP treatment in hopes of it giving me better sleep quality and getting me off some of this depression/anxiety medication in the long term. When the results were initially sent to the DME, a lady there which has continually been rather short, rude, and obnoxious with me right away stated that my score wasn't a 5 or something so it didn't meet the criteria provided by them from the insurance companies to get re-embursed for equipment thus the refusal to issue it to me. When I had called my insurance then to appeal, of course they told me that there was nothing turned in to appeal. I called back the DME and practically begged her to at the very least just submit it and she refused. I called back the insurance and explained everything to them and told them about my doctor really feeling this would benefit me in many ways and what rights I had to pursue this for a claim and they said the doctor could write an order for pre-authorization which would take 4-6 weeks. So I contacted the Dr office and explained and they agreed to do this which they did. I patiently waited out the 4- 6 weeks and finally at about the 8th week I received a copy of the pre-auth from insurance dated 3/27/12 but the service date was listed as 2/10/12. So the Dr faxed this to the DME and a week went by and I didn't hear anything so I called the DME and spoke of course with that same lady which right away told me the pre-auth was no guarantee of payment (to read the fine print on the back...) and that her supervisor was out of town for another week so she wasn't doing anything until then. The next week passed and still not hearing anything, I called the DME back and now was told not only did the pre-auth expire and it was for a 1 month rental but they weren't going to do anything anyhow still based on the magic number 5 which I didn't meet.

So anyhow to present... I finally was able to speak directly to my doctor and while he is still standing behind this DME and telling me that the insurance company is messing with me, he told me before I buy a machine and mask retail like I told him I was about to do, to give it one more shot and call my insurance requesting that they re-authorize and put a current date on the authorization then he will contact the DME and press them to atleast submit it to insurance. Yea, this whole process has been unbelievable to me. I've put in countless minutes/hours on the phone back n forth seeming like I'm the only one truely fighting for what should/could be owed to me for my health.

Some things off the recent in home sleep study through NovaSom: (if I'm reading it right...)

First night: 2 obstructive apneas, 20 Hypopneas, Oxygen Saturation: 100-95% .07, 94-90% 7:16, 89-85% .05, 84-80% less than 1 min.

Second night: 4 obstructive apneas, 17 Hypopneas, Oxygen Saturation: 100-95% 1:40, 94-90% 5:37, 89-85% .02

Third night: 3 obstructive apneas, 15 Hypopneas, Oxygen Saturation: 100-95% :43, 94-90% 6:30, 89-85% .08, 84-80% less than 1 min.

Totals: Snoring over 73% of time. - Time over 50dba 1st night: 5:21 hours, 2nd night: 5:48 hours, 3rd night: 4:52 hours

[Janknitz]

I'm going to make some blind guesses here that your sleep study results were not sufficient to meet the Medicare criteria for CPAP, and since most insurers follow Medicare guidelines, the DME just doesn't want to take a chance that your insurer will reject the rental after the fact. (And yes, insurers often deny a claim, even after granting pre-authorization).

You can try looking online for your insurer's criteria for CPAP coverage or ask them if they will send it to you.

Failing that, you can try other DME's if your insurer doesn't limit you to that specific one.

[RandyJ]

Some of the depression and anxiety meds have implications for sleep quality, particularly affecting the deeper stages of sleep. You may want to search this forum and google using the medication names and terms such as sleep quality or REM sleep and see what comes out...

[Julie]

viewtopic.php?f=1&t=70205&p=656899&hili ... al#p656899

That's the story of someone who systematically went through the process from study to Apap and back - it's not for everyone, but probably for a lot more than they realize, and you sound like you just might fit in the picture... take your time with it because it's worth it.

[VikingGnome]

Actually, I'm not so sure CPAP would help accomplish deep and REM sleep. Your sleep apnea is nonexistent. Less than 5 episodes per hour is considered "normal" so nothing to treat. Medicare will pay for CPAP if your AHI is 5-15 AND you have a complicating medical condition like hypertension, heart disease, etc..

Sounds to me that your main problem is inadequate restorative sleep. You need to have a serious talk with your doc about cutting back on your antidepressants, especially if they are SSRI or SNRI meds. They are notorious for suppressing REM and deep sleep. My doctor cut my Effexor dosage by 1/3 after sleep doc told me that my OSA was under good control but I still on no REM or deep sleep. Since the med dosage reduction I've been having up to 2 hours REM sleep per night but still negligible deep sleep.

Medications and sleep quality are deeply intertwined. Sometimes the best thing to do is cut back the meds and let you get some restorative sleep. Check all your meds and see which suppression REM and deep sleep. You may find that your problem is your meds and CPAP won't do you any good.

[JayC]

I "barely" met the criteria as well, as my obstructive apneas are positional (and I do not knowingly sleep on my back!).

I was de-sating

I have a long history of cognitive fogginess, and non-restorative sleep.

Because of these, my "score" was not the only consideration in the coverage equation. And I have Medicare. And the doc that started the whole process was my Psyc doc who was treating me longterm for depression symptoms (which are now seen to be as a RESULT of brain and sleep issues rather than the other way around!!).

Really not sure how a DME can stand in the way, short of just saying "we don't want your business".

[lazer]

...
Going without insurance involvement......
Personally...if it were me...I would go with a Respironics PR System Auto Cpap with AFlex (APAP)....the data available is a bit more comprehensive than on the Intellipap Auto (APAP) and the price isn't all that much more. The Intellipap lacks a bit of data that I find rather important.
You can get one of the new PR S1 APAPs in the heated hose 60 series for $649..that includes humidifier.
I can help you with the software.for the reports.
The slightly older model PR S1 APAP was $619 last I looked (includes humidifier).....

Would that be this one: https://www.cpap.com/cpap-machine/respi ... -flex.html