New, and need advise

saldivar · Post by **saldivar** » Sat May 20, 2006 9:08 pm

My name is John , age 28 and I have been just diagnosed of having High -level sleep apnea. From the sleep study I was told that I would need a cpap. with auto setting, humidifier and pressure setting of 18. CFlex if available. I was told at first that my insurance would cover all cost not it turns out that they cover nothing and the machine cost over $1400, I am a student and cant afford that amount. I was wonder first of all should I change my insurance and what should I look for as far as coverage for the machine. Second can I rent a machine instead of buying one right now, last the doctor said some people use recliners instead of CPAP, is that a wise decision, thanks for any info you may have.

Handgunner45 · Post by **Handgunner45** » Sat May 20, 2006 9:21 pm

It will probably do no good to change your insurance. As you have already been diagnosed with OSA, any new insurance carrier will most likely exclude any coverage for treatment. Your best bet is to get a copy of your prescription from your Dr. and go to an online dealer such as the sponsor of this forum, CPAP.com

Wulfman · Post by **Wulfman** » Sat May 20, 2006 9:21 pm

John,

Did your insurance pay for a sleep study and doctor appointments? If so, what is their reasoning for not covering the costs for your therapy (machine and mask)? Seems a little odd to me.
If you have SEVERE apnea, sleeping in a recliner won't make enough difference to really help you. It might help SOME, but I wouldn't count on it.

You might want to do some reading on this site and check out CPAP.COM for prices on machines and masks. Did your doctor give you a prescription for a machine? If so, you could buy from CPAP.COM and save lots of money.

Best wishes,

Den

rested gal · Post by **rested gal** » Sat May 20, 2006 11:14 pm

The machines I'd be considering, if I were prescribed a pressure of 18:

ResMed S8 Elite with EPR $499.00 -- straight cpap machine with pressure reduction relief when you exhale.

If I had to have a straight cpap machine for financial reasons, then I'd want one with an exhalation relief feature that keeps the pressure dropped an exact number of cm's throughout the entire exhalation. ResMed's "EPR" does that. Respironics' "C-Flex" drops only at the start of the exhalation, then lets the regular pressure back in before the exhalation is finished.

Respironics' C-Flex is very comfortable to me at pressures of 12 and below, but it isn't helpful at all when I experimentally try to exhale against pressures such as 15 or more...C-Flex can't make a dent in it for me at high pressures. The point at which C-Flex isn't very useful would vary, of course, depending on how forceful a person's exhalation is in the first place.

ResMed's EPR, however, if set for "3", will give an exact drop of 3 cm's and maintain that reduction throughout the exhalation, no matter how high the pressure.

ResMed's EPR comes as close to being like the comfort of exhaling on a bi-level machine as you can get with a straight cpap machine.

Respironics REMstar Auto with C-flex $725.99 -- autopap machine with pressure reduction relief when you exhale.

Autopaps are set for a range of pressure and can automatically vary the pressure as needed. You might not need that hurricane force pressure of 18 all night. Perhaps you need 18 only when in REM and/or when sleeping on your back.

An autopap can be set for a range (say 11 - 20) around your prescribed pressure. You might spend most of the night down at 11 or 12 or 13 and not have to hit 18 much at all.

If you are thinking about getting a bi-level machine (commonly called "bipap") I'd get the:

Respironics BiPAP Auto with Bi-Flex $1,479.00 -- combination bi-level and autopap in one machine.

For only $100 more than the cost of just a bipap machine, you are getting bipap AND autopap together with this machine...the best of both worlds, imho.

$1,479 sounds like a lot of money...and it is! But that particular machine could make a WORLD of difference in getting effective, comfortable treatment in two ways at the same time.
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Heated Humidifier:

This is just my personal preference...to get a separate humidifier rather than an integrated one.

I like the:

Fisher & Paykel HC 150 heated humidifier $179

Can be used with ANY machine of any type.
If you change machines later, you can still use this heated humidifier with the new machine.
You won't ever have to spend more money on another different "integrated" humidifier that might work only with one brand or model of machine. The F&P humidifier can go from machine to machine to machine.

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Mask:

Respironics ComfortLite 2 $89.99 (Be sure it has "2" in its name.)
Med. and Large nasal pillows
Med. and Large "simple cushion"

If you need to breathe through your mouth, get this mask to cover nose and mouth together:
ResMed Ultra Mirage FF (full face.) $142.00
Go to your local DME to get fitted for the full face mask, but do not buy it from the local DME.
Buy the mask from an online store or through an auction site like Yahoo Auction or eBay.

chdurie2 · Post by **chdurie2** » Sat May 20, 2006 11:26 pm

salviadar:

i agree that it makes no sense that your insurance company would pay for an expensive sleep study, go to the trouble of giving you a diagnosis, tell you that you need a pressure of 18 (high) and then not pay at least part of the therapy (the machinery, etc.)

i suggest that you put all of this in a letter to your insurance company and inform them that you will therefore hold them liable for any accident that occurs as a result of their refusal to provide proper treatment for this serious problem. send a copy to your state insurance department and follow up with them -- some state insurance departments are very pro-consumer. you may see some result.

or at least re-check your policy.

caroline

Guest · Post by **Guest** » Sun May 21, 2006 11:07 am

Thank you for your replies, The Doctor prescribed me a Remstar Auto and a humidifier, when it totaled up without insurance it was way to expensive for m to pay by my own. Yeah its kind of weird, they order my machine take my measurements and then when its suppose to be delivered at my home I get a call that im going to have to pay in full and a $250 setup fee, I thought then Id never get a machine.

Trouble_Is · Post by **Trouble_Is** » Mon May 22, 2006 8:45 am

I'm in the same boat that you are. After a cardiovascular stress test, ultrasound on my heart, an angiogram, several antidepressant prescriptions and a sleep study, I was diagnosed with obstructive sleep apnea in February. My insurance company has spent well over $50,000 to get me diagnosed correctly but tells me that my sleep study didn't "meet the Medicare minimum requirements for CPAP therapy" and will not spend the $1,200 or so to get me set up. The Pulmonary doctor that "read" my sleep study fired off a letter to my insurance stating that I, indeed, needed CPAP therapy and I followed up with my own letter reminding them that operating a locomotive attached to a 13,000 ton train while sleep-deprived wasn't good for me or the general public. They still refused so here I am, after having just purchased the equipment PRESCRIBED for me by a qualified physician. I have yet to recieve my machine (just ordered it Thursady), so I'm sure I'll be posting again in the near future with lots of questions. Whew! Thanks for letting me vent.

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CPAPopedia Keywords Contained In This Post (Click For Definition): medicare, CPAP

roster · Post by **roster** » Mon May 22, 2006 9:29 am

IMHO you should proceed in this order:

1. Do not speak in a hostile manner or make threats to the insurance company.
2. Talk to a supervisor with your insurance company.
3. Have the insurance specialist at your doctor's office talk to your insurance company.
4. Have your doctor talk to the supervisor or medical director at your insurance company.
5. Have your doctor write a letter to the medical director of your insurance company.
6. Do not threaten legal action until you consult with a lawyer.

I found my doctor's office and the doctor himself were very helpful in dealing with my insurance company.

txtornado · Post by **txtornado** » Mon May 22, 2006 11:51 am

Did your insurance pay for a sleep study and doctor appointments? If so, what is their reasoning for not covering the costs for your therapy (machine and mask)? Seems a little odd to me.

i agree that it makes no sense that your insurance company would pay for an expensive sleep study, go to the trouble of giving you a diagnosis, tell you that you need a pressure of 18 (high) and then not pay at least part of the therapy (the machinery, etc.)

You are both right that it makes no sense - but it happens. My insurance paid for the sleep study that diagnosed me with severe OSA, minus my $300 "co-payment". But they did not cover any of the cost of the XPAP equipment. I had to pay for all of it out of pocket. It made no sense that they'd pay to diagnose me with something and then not pay to treat it, but it is specifically written in my policy that treatment of sleep disorders is not covered. Crappy and stupid, but true.

Saldivar - If you haven't already done so, I would review your insurance policy carefully to see if treatment of OSA/sleep disorders is specifically disallowed. If it's not, and the insurance company says they won't pay for some other reason that can't be backed up by your written policy, you may have some success by getting your doctor involved as rooster has suggested. If that doesn't work, your best bet will most likely be to buy online. I haven't heard of a place that rents out XPAP machines unless it is through insurance. I bought all of my equipment from cpap.com and got a good price and good service. Best of luck to you.

datasmom · Post by **datasmom** » Mon May 22, 2006 5:57 pm

A LOT of insurances deny absolutely everything the first go around. Sometimes you can get them to cover things they've denied by being "nicely" persistent. Also, try working with your doctor and your doctor's office personnel. Sometimes they can help you get the insurance company to cover what they have flatly denied several times.
Sometimes the problem is with the coding of the equipment, the procedure codes chosen and the diagnosis code as well. The diagnosis code is the most important one as your insurance's computer software will often automatically deny due to an inaccurate diagnosis code with no human involved. So, again the key word is "nicely", ask your doctor's office to do a code review.
Ask your insurance what their appeal procedure is and follow it. Sometimes all they want are the medical notes from your doctor and the sleep center. They are in the business of making money, at least the private insurances are... medicare is another story altogether... I would not give up at the first denial, make them ("nicely" make them that is, polite goes a LONG way in the insurance business) review your situation.
If you need the medical codes reviewed, I'd be glad to do it, I'm a certified medical coder..... Lorrie

Grimace · Post by **Grimace** » Mon May 22, 2006 7:30 pm

I may get in trouble for saying this, but I'm going to anyway. I was in much the same boat as you. I didn't have any insurance, and didn't have the money to pay for a sleep study, but was confident that I had obstructive apnea based on my symptoms. I purchased a used Remstar Auto with a heated humidifier, hose, mask, the whole shootin' match, with only about a month of use on it, from an individual for a bit more than $400. I was desperately in need of some relief, and my feeling then, and now, is that it's just air, and the worst that could happen was that it didn't work. Fortunately, it worked very well indeed. You don't even have to deal with the issue of uncertainty, as you have the study results. If you think you might be interested in taking this path, there is a very nice Remstar auto for sale on yahoo auctions at a buy price of $450 with everything except a mask.

SuxBeingU · Post by **SuxBeingU** » Mon May 22, 2006 8:15 pm

I would talk to your Dr. My Drs assistant handled everything all I had to do was wait for the machine. They know what to say and what the insurance Cos are looking to see. Try explaining to your Dr whats up.

Whos your INS BTW

I have Blue shield they paid 100% .

Side note-- Just ( 5 mins aggo) got the explainantion of cost for a Nuclear test I took to check my lungs COST 2561.00 for 1 test. WOW

Guest · Post by **Guest** » Mon May 22, 2006 11:22 pm

thanks for all your help, I just found you guess and already you have helped me so much.
My insurance right now is Healthnet, but maybe I will switch to Bluecross, what should I look for as far as coverege that will beused towards the machine, thanks for any info

rested gal · Post by **rested gal** » Tue May 23, 2006 1:24 am

Grimace wrote:I didn't have any insurance, and didn't have the money to pay for a sleep study, but was confident that I had obstructive apnea based on my symptoms. I purchased a used Remstar Auto with a heated humidifier, hose, mask, the whole shootin' match, with only about a month of use on it, from an individual for a bit more than $400. I was desperately in need of some relief, and my feeling then, and now, is that it's just air, and the worst that could happen was that it didn't work. Fortunately, it worked very well indeed.

Grimace, with no insurance I did almost the same thing. Was lucky enough to know a family doc in town that was willing to just write me the Rx. No study. I didn't know at that time that autopap machines were sold in online auctions or I'd have gone exactly the route you did.

If a person has to do it via autopap and no study, it's very helpful to get the software to monitor one's own treatment.

Here's what I did...has worked well for me, just as it has for you, Grimace:

Aug 16, 2005 subject: sleep or lack thereof

Here's what a noted sleep doctor thinks of doing that, if need be:

Not Every Patient Needs to Go to the Sleep Lab Powerpoint presentation by a well respected board certified sleep doctor/pulmonologist, Dr. Barbara Phillips, at a meeting of the American Lung Association of the Central Coast - November 2004

Effie · Post by **Effie** » Tue May 23, 2006 9:52 am

I have similar issues with my insurance company. They paid 100% of my first night and titration sleep studies.. but only paid 20% of the cost of my machine... and that was after the $400 deductable was also used on the cost on the machine. So basically the insurance, after spending $6000 on sleep studies, paid $20 on my machine. I am going to have to buy my equpiment myself.

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