Insurance claim denial

[LMDanley]

I need help. I just received a denial from BCBS of Missouri for my CPAP machine rental. They cited the reason as "investigational or experimental".

I have a Remstar Auto CPAP with C-Flex. I feel so much better since I started using it but I can't afford to pay $385 a month to rent the CPAP. What can I do?

Are they just denying it hoping I'll go away or do they just need more information from the doctor on my condition? I've had a sleep study and was diagnosed with Severe Obstructive Sleep Apnea and I've had a MLST because I was still sleepy during the day.

BCBS approved me to have Modafinil (Provigil) which runs $400 a month but not a CPAP machine. The rules say for it not to be investigational or experimental it has to be FDA approved, not the subject of clinical studies or trials, etc.

Do I file an appeal? Scream alot? Or call American Homepatient for help?

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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap machine, auto cpap, C-FLEX, CPAP

[snoregirl]

I am sure that there are better people to respond to your questioin but here is what I know.

It appears that your went and got the APAP without checking (prequalifying) with your insurance. I don't know what you do about that one or why the DME wouldn't have done that. My DME charged me only for my copay 20% the day I picked the unit up.

What I do know is that I would STOP NOW with the $385 per month rental. For less than 2 months of that rental you can order the same machine from Cpap.com and it will be yours.

I would think that if your doctor prescribed it the insurance should pay but who knows what that will take to make it happen. I personally had trouble with my insurance for an Auto since they called it deluxe equiptment (not BC/BS). 2 month fight. But I had picked up a used CPAP that I was using while I fought.

CPAP is not experiemental that I know of. Auto CPAP a lot of insurers fight.

I would fight, but I would definately not pay another months rent to whomever you are renting from. Use up your month while fighting (unless you can return it immediately and get a total credit), but get that thing back and buy your own at a reasonable price if APAP is what you need.

How long have you had the machine? Have you put in an appeal to your insurance company? Has the doctor who wrote the script for the machine stepped in to help with the insurance company? Would your insurance company have a problem with straight CPAP (not Auto)? If so can you swap in the first month for a CPAP so that the insurance company will pay their portion. Then you still would have the option of ending the rental and going and buying the APAP somewhere else like CPAP.com if you really wanted an APAP or using the CPAP while you fought for the APAP.

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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap.com, CPAP, DME, auto, APAP

[roztom]

Typically all you need is a prescription. I have BCBS of IL, Even after they paid their part of the sleep study and the Doc wrote the prescriptipon for the machine, etc., they denied the claim and sent me a "Physician's Letter of Medical Necessity."
The people who rent you the machine will not cut you off from treatment, they do not want the liability. Ask them.

Then call BCBS and tell them you want the "Letter of Necessity." Take it to your Doc and keep after him to get it taken care of.

SO far this has ben my experience with BCBS. They know the diagnosis of OSA, they got a prescription for the machine and they still want to bust
%#@&*. These are the hoops they make you jump thru.

I've had my xPAP for over 3 months and my Ins hasn't paid anything yet but I have paid my co-pay to the RT.

Don't give up. Call them and tell them the chain of events and get your Doc to help.

Good luck,

Tom

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CPAPopedia Keywords Contained In This Post (Click For Definition): Prescription

[Offerocker]

First, I'm surprised that you received an AUTO right off the bat! I'm still battling for that, instead of a CPAP/CFLEX.
I have BC/BS (FED'l, which is the worst), talked with a nice rep who told me there is ONLY ONE CODE for a CPAP machine. They pay one set dollar amount.
Yes, I agree, that if you don't have 'Standard' coverage, you may need to get pre-approval. Sometimes, if they are nice, it could be retroactive, ESPECIALLY since the supplier has yet to file an insurance claim. Or, they may KNOW that the insurance won't cover it, and are purposely allowing you to do the paperwork, knowing that you're the one who will be stuck with the difference/loss due to upgrade.

My supplier says that my insurance won't cover APAP. Well, I doubt that, and informed that I have additional policies that would pick up the remainder anyway (I hope). They are fighting me, and the NP who wrote the Rx, believe it or not. They are judging what I get, not the NP.

Talk nice to your insurance co and try to get something in black & white (ref handbook, etc., plus supporting info). Too bad the supplier chose to put you in the middle.

By the way, I went ahead and purchased a nice new (NEW, not a used one from a supplier) APAP CFLEX with bells & whistles from CPAP.Com - their prices and services are the best. And it only took one phone call and a Fax of my Rx. Piece of cake. Sometimes it's worth scraping up the bucks for peace of mind..........although............I DO hate to see suppliers take advantage of us. I was too far into the rental before I 'got educated' from people in this forum.

Good Luck, and keep us informed.

[Bingo]

I need help. I just received a denial from BCBS of Missouri for my CPAP machine rental. They cited the reason as "investigational or experimental".

A couple of things that may help you here.

1) First off, there should be a phone number on your denial letter that you can call with questions. Call them and find out why it is being labelled that way.

One common reason for such a situation goes like this: A CPAP might have a billing code of E0601. This is covered for a diagnosis of Obstructive Sleep Apnea - CPT Code 780.53.

Now lets say for example the particular autopap you recieved happened to get classified as a type of ventilator (not all that uncommon as these two types of products get closer and closer) and assigned a code of E0470.

When BCBS systems look at this (Remember that a vast majority of claims are processed automatically, not by a person) it will look at this and say 'Well now, an E0470 ventilator has not been proven to be proper treatment for an OSA diagnosis of 780.53. They don't match up properly. When used in this manner, a ventilator is really still expirimental.

I'm not saying that is definately the case for you, but it happens very often.

The other case would be BCBS genuinely thinks the particular unit you have is expirimental. If this is the case, asking to speak with a Case Manager or Review Manager should clear the matter up.

In either case, I know I would and I'm sure others would be interested in hearing how this turns out for you!

Bingo