Replacement Equip - Insurance??

[40 Winks]

Does anyone have any experiences with getting the insurance company to pay for new equipment? Did they pay or not.

I received my bare bones equipment from Apria in August of 05. I now have a new doc, and I'm sure he will Rx a new machine, auto, heated humidifier, and full data. Just not sure the same insurance co. will buy it.

[kest874]

Easiest thing to do is call your insurance provider and ask.

[Wulfman]

Does anyone have any experiences with getting the insurance company to pay for new equipment? Did they pay or not.

I received my bare bones equipment from Apria in August of 05. I now have a new doc, and I'm sure he will Rx a new machine, auto, heated humidifier, and full data. Just not sure the same insurance co. will buy it.

You probably won't know till you ask. I've read that many/most insurance providers won't replace them for five years. If your doctor prescribes one, they "might".

Den

[carbonman]

I now have a new doc, and I'm sure he will Rx a new machine, auto, heated humidifier, and full data.

Have him write a RX for an auto, then they have to change it.
" Apap of patients choice"
Then tell them what you want.

Be sure to get the RX in YOUR hand first.

[sleeplessinaz]

Hi--I got the bare bones Resmed Escape but I changed insurance in 2008 was able to upgrade everything with a new script but then again I switched from BCBS to Cigna/Apria ---I love Apria --no problems. They are great!!

Carrie

[old64mb]

Everyone's been correct so far, but I'll fill in a couple of gaps.

In general, many insurance companies follow Medicare rules on both when you're eligible to be prescribed a CPAP (e.g. AHI >15 or <15 + other stuff) and when you can reimbursement schedules (e.g., how often you can get a new mask, humidifier, etc).

Medicare lets you get a replacement machine once every 5 years. However, I have been told that there are some insurers that will let you do so more frequently. Finding this out from your own may or may not be a call you want to make, as I'll get to in a second.

The way around this is if the underlying medical condition changes so that the machine you currently have is not capable of meeting it. That is, if you currently have a bare bones CPAP and you can convince your doctor that you require a higher-functioning machine (APAP/BiPAP, etc) because it's medically necessary because of what it does differently for you than a CPAP, then insurance companies will cover a new machine, since it's a new prescription. Carbonman's suggestion is a good one - an APAP is considered a different machine if it's medically necessary to have the capability.

The key to this, though, is that you've got to find out what the requirements of your particular insurer are to have your new prescription be considered legit. Note that data capability is NOT medically necessary, and I suspect they won't cover a new full setup just because you don't have a humidifier either. You also probably don't want to be on record calling and asking "so when can I get a new machine since I don't like my old one?" to your insurers CSRs, since once you submit a bill for the new one they'll look at that note in your record and start asking questions.

Where you stand a much better chance is finding out if a new titration study is something they'd cover because it's been over 3 years, at which point the doc can order an APAP because most insurers will cover one in lieu of another PSM. After that, it gets slightly trickier - you'll have to meet the CPAP failure requirements, like being unable to stand >10 cm of pressure, and those requirements vary from insurer to insurer. Those are better topics to bring up than replacement schedules if you call, and better yet if you can find those policies online you won't even need to do that.

Much easier if you just switch insurers. Do make sure to have everything set up before you go into your doc's office, since that'll help you get the script required to pass through their hoops.

[40 Winks]

Thanks all. Old64 - Switching insurance companies is not an option. And I had the same thoughts as you about setting up a red flag by investigating by coverage with the insurance coverage.

My new doc set up tests for me, went to the PSG 2 weeks ago and have the titration tonite. I just not getting the proper therapy with my current set up and I guess I'm a bit anxious about getting some equipment that will work for me. When I first got my equipment it took quite an effort to breath thru my mouth, now it takes no effort at all. I was thinking the machine was not pushing out the required pressure any more, but they tested it and it's working fine. Maybe my pressure just needs to go up.

When I went for my PSG the tech let me try a nasal pillow, among other things, and I really liked it. So, I ordered one and received it yesterday. Tried it out but the back pressure was inflating my sinuses and it felt like my eyes were bugging out. Don't think I can use it without some kind of exhalation relief so I just stayed with my old mask with a new cushion.

My experiences with Apria have been far from happy. The reason the insurance companies allow such huge margins on medical equipment is because they expect the DME to educate the patient. No options were ever presented to me at the beginning, and I don't think 10 minutes of showing me how to turn the machine on and connect the mask and hoses qualifies Apria to charge $1K for the machine only (they charged everything else separately under different codes). I suppose my family doc at the time shares some responsibility, but I'm sure he relied on the DME as I did. Further, one order I placed never came - when I called back they had no record of my order but did say my Rx needed to be updated - maybe that was too much for first tech that took my refill order. Another time, I ordered supplies at the beginning of December so I could get them in before my deductible started anew in January. Got my order timely, but they didn't get around to billing my insurance until the end of January so I had to pay the annual deductible 6 months sooner than I would have otherwise.