Blue cross actually paid up!

[cnaumann]

After getting the run around from my local DME about getting an ASV machine back in November, i took some advice I got here and just ordered an 'open box' machine from Secondwind CPAP. After using it for 30 days, I took the SIM card to my sleep doc and asked him to write a letter saying that I was using the machine and that the therapy was working. I also got a copy of Blue Cross' coverage guidelines and went through it line by line. I highlighted certain key phrases and asked my doctor write a letter saying that I had met the criteria using the exact language in the document. If it said "patient must fail CPAP trial"' write "patient failed CPAP trial diring sleep study on October 14." And so on. My doctor was happy to do this. They were fairly short letters.


faxed Blue Cross about 16 pages of stuff early in December. And waited. And waited.


Lo and behold, a got a check back for 80% of what I had spent. This was far more than I expected, I thought there would be a large deductible (I have at least 11 different deductibles on this policy) and I though that it would be covered for 50% at the most. Oh yeah, postage was listed as 'surgery' and was not covered. It also says the machine is rented, but it is not. I did not ask... I put the check in the bank. I kind of feel like I have won some sort of victory here!

I still do not understand the replacement guidlines.

It says something like:
Fully face mask, every 180 days
Nasal mask or pillows every 180 days.
Nasal cushion every 180 days.
Headgear every 180 days
Hose, ever 120 days
Machine every 3 years.

It is not clear if one thing excludes another thing. Can I get a face mask and a nasal mask every 180 days? I need both due to seasonal allergies.
Can I get a set of pillows and a full mask in 180 days?

It also says I can't get anything for 10 months during the 'rental period', the DME is supposed to take care of all replacement parts during that time.

Of course, I want to buy replacement parts online.

This is small stuff. I am almost afraid to call them because I am still in shock that they sent me a check.

[Pugsy]

It is not clear if one thing excludes another thing. Can I get a face mask and a nasal mask every 180 days?

Usually one excludes the other...it's one mask (type of your choice) per 6 months.
Looks like the way it's worded...extremely limited and an either or choice you have to make.
For nasal pillows alone you probably would be money ahead to buy them from an online source or EBay and use whatever your insurance might allow towards the most expensive of your mask choices.

[Thewino]

Cnaumann,

These insurance giants put up so many impediments to deter the average person from following-through to get payment. Congratulations are in order. I'm very happy to hear that you jumped the barriers and got payment for a service that you already pay for and that should be much, much simpler for people to seek reimbursement.

They probably haven't thought it through. If you can get someone who qualifies for CPAP/BIPAP to utilize the proper therapy you are practicing preventative medicine and the insurance companies would probably save a ton of money not paying out monies for acute medical care for those that don't accept therapy.

Nicely done,
TheWino