Denied AGAIN

[LisaEileen]

Medicaid denied my bipap for the second time. I don't know if I want to cry or if I want to scream. I was told that I'd have to go through an appeal process to try again. I don't understand this. How can they deny paying for something that my doctor has clearly stated I NEED? I have to call my doctor and find out what to do next. I am so upset about this. i finally got an answer to why I am having so many health issues. All I need to get healthier is AIR. My insurance company is denying me AIR. How crazy is that?! I can't even imagine what my doctor is doing to tell me now. Probably buy my own or suffer. If you look through my past posts, you will understand why buying one is simply not an option right now. I had to stop driving anywhere farther than in town because I can't trust myself to stay awake. I am considering whether I can go back to my crossing guard job on Sept 1 when school starts up again. I'm so tired it's hard to stay awake even for that. I NEED a job. I can't just sit around napping in chairs all day. This is proof that insurance companies don't care about the patients best interest. dxsdf

[Gerald]

Welcome to the wonderful world of Socialism.

The meaning of "Socialism" is simple....it means "we don't have a choice".

When we trade our votes for Socialism, we are "doing a deal with the devil"......and he then "owns us".

[Julie]

Gerald - just how helpful was your rant to the person asking for help? And what the heck does socialism have to do with her problem anyhow? She certainly needs to talk to her MD again, find out what the problem is, maybe talk to her insurance co., but apart from anything else, she needs help. As far as 'socialism' goes, you're in the U.S. no? Well you have one of the last "free enterprise" medicare systems in the world - nothing about it is socialistic, whatever might happen in future. How could you possibly come up with that response?

[GumbyCT]

I think what Gerald is trying to say - w/o knowing any of the details such as dx, Ins. Co. etc. we can only make assumptions. My assumption is that your Ins. won't pay UNTIL you fail CPAP. Your Ins. prob doesn't want to pay for a BiPap until you (your doc) proves that you will use it and it will help whatever your dx is.

So yea, you need to talk to your doc. Or pay out-of-pocket. No I won't be searching to find out what or why. If you want me to know, tell me else I'm goin to sleep.

[Pugsy]

Medicaid is the "insurance" involved. Medicaid is pretty much state by state with huge variances between states on how it is managed. Medicaid will usually use any excuse possible to deny anything that will involve much of a funding expense. BiPaps are more expensive than run of the mill CPAPs. Medicaid will dictate the hurdles that must be jumped before they will fund such an expense. They hope people will give up and not go through all the hurdles. One of the hurdles might be plain CPAP failure. Each hurdle must be isolated and systematically addressed to have any hope of Medicaid covering the expense. They do not put a human factor in any of this. They crunch numbers and facts. They won't factor in the fact that allowing for this device might improve a patient's life such that they could get off Medicaid. It is simply an ugly fact of life regarding the Medicaid system.

The Medicaid hurdles must be jumped and dealt with or look for alternative source for the machine. Private purchase used? Church might help? Someone might help? There are organizations that try to help people who need things. I wouldn't be sitting back holding my breath waiting on Medicaid while I jumped all those hurdles.

I wish I could offer some specific place where help might be available. Only place I have ever seen mentioned for the financially needy is the A.W.A.K.E organization but I know nothing about them and what hoops they have you jump through to qualify.

http://www.sleepapnea.org/awake/groups.html

[jules]

I think you need to check with your local medicaid people on what they will and won't cover. Medicaid is run by the states I understand with federal money. They get to pick and choose what they will cover.

Read the posts by karla1958 about her adventure. This gets you to the list of her posts - pick and choose from there - you might want to check out all of them.

search.php?author_id=37789&sr=posts

the charity program is awakeinamerica.org I believe - not awake support groups

[Pugsy]

the charity program is awakeinamerica.org I believe - not awake support groups

Oops I stand corrected. I couldn't remember the exact name, only the AWAKE part of it. So sorry if I confused anyone.

[LisaEileen]

Thanks for the info.I'm going to check out that site. I hate asking for help, but in this case, I may not have a choice. The $ issue I'm having is that I have a 4 year old with Autism. I cannot work a lot of hours due to the care she needs. I work a crossing guard job during the school year. The economy stinks and my husband has been getting a lot less hours lately. We're barely making it. There's no way I can pull money out of anywhere to get a machine. My dd wasn't able to get the therapy she needed this summer because Medicaid denied that too and we couldn't come up with the money to pay for it. My husband is looking at a job that might be opening in September which offers health insurance. The company he works for now doesn't. This entire process has been absolutely ridiculous. I've been doing this since April. My Mom and Dad both had sleep studies and had a machine within 2 weeks of the study. I can't live like this. I've had to quit driving any farther than around town because I can't trust myself to stay awake. My dd's doctors are all a 40 min drive. I've had to cancel appts for her if I cant find people to drive us. I guess there's no point in complaining about this anymore. There isn't much more I can do but wait and see what else my doctor will come up with.

[ozij]

There isn't much more I can do but wait and see what else my doctor will come up with.

Tired as you are, there are things you can do, as jules has pointed out:

Look for info on what you state's medicaid's rules are for bi-pap coverage.
Check if you doctor is following those rules to the letter.
If they want you to "fail cpap" first, ask the doc. for a cpap Rx that medicaid will cover.
Find out all the hoops, and go through them. Don't wait for you doc - help him. The emphasis in jules' quote is mine:

I think you need to check with your local medicaid people on what they will and won't cover. Medicaid is run by the states I understand with federal money. They get to pick and choose what they will cover.

Read the posts by karla1958 about her adventure. This gets you to the list of her posts - pick and choose from there - you might want to check out all of them.

search.php?author_id=37789&sr=posts

the charity program is awakeinamerica.org I believe - not awake support groups

[jules]

Again, Medicaid may not pay for apnea treatment in all states. Each state has a list on what they will use Medicaid funds to pay for.

It might help if you posted what state you live in - we have ppl from all over the world and you might have someone from your state also on Medicaid post or pm you about their experiences.




Does your doctor know of people on Medicaid who have actually gotten machines even bipaps?

What is his personal experience on getting machines for people on Medicaid?

Have you called local churches and asked for charity considerations or asked if they had a member who died and left a machine to be used by someone who needed it?

Have you checked local AWAKE groups - this is where you check that site pugsy posted, contact them and ask if they know about machines available for charity cases? Sometimes they might have ideas. Sometimes local DME's have ideas or "free" or minimum cost clinics have donated machines.

Have you checked local thrift stores or craigslists for machines?

Have you checked out that awakeinamerica.org program about what they can offer? You want to look at their relief program (donate relief part).

Have you read karla's tale and how she got a machine?

I think you have a full few day's agenda here just to complete this list as busy as you are a lot of the time with kids underfoot.




Medicaid may not pay for any machines in your state.

Not all private insurance pays for machines either.




If you want treatment, you have to do the legwork.

[mars]

I had to stop driving anywhere farther than in town because I can't trust myself to stay awake.

Hi LisaEileen

I feel for you. I was once the first car stopped at lights on a main highway during rush hour, the next thing I knew I woke up and the road ahead of me was clear of cars. The road behind me was full of cars. I had to stop driving in the late afternoon.

This was before sleep apnea treatment.

For short-term help - just to get you around in more safety - you might want to check out

http://www.nonap.com.au/

It may just give you that extra safety and distance that you need whilst sorting out all the hassles. Or it might just keep you safer on the shorter distances.

For myself, if I had known about it before I knew I had sleep apnea, I would have got one.

Stay safe, and keep at it

cheers

Mars

[LisaEileen]

I live in WIsconsin. When the Health care agency called and told me they got another denial letter, I asked them if anyone on Medicaid ever gets approved for a bi-pap. She told me yes. I asked her if there was a way to get a low cost machine or if there's a way to get a donated one. She said no. I feel like I don't have enough info on my own diagnosis to call and talk to anyone about why I need one. My doctor doesn't want to give me the full report until I try my bipap for 3 weeks. All I know is that he said he's only seen 6 other patients like me in his many years of doing this. I don't have a lot of apnea episodes, but I struggle to breathe 75% harder than a normal person. It sounds like I will never fit into Medicaids criteria for needing any machine whether it be cpap, bipap or whatever because I don't have enough apnea episodes to make them happy. It doesn't matter that I struggle to breathe and that it only took me 2 min or less to fall asleep at my naps at the sleep study. I'm sure you all know that this is all way harder when you are as tired as I am. I was so depressed for awhile about a month ago, that it took everything I had in me to leave my bedroom every day. I'll have to see if I can get my Mom or someone to help me make phone calls. I'm so tired most of the time I can't think straight to make a complete sentence that makes sense.

[Rustyolddude]

I live in WIsconsin. When the Health care agency called and told me they got another denial letter, I asked them if anyone on Medicaid ever gets approved for a bi-pap. She told me yes. I asked her if there was a way to get a low cost machine or if there's a way to get a donated one. She said no.

You might try http://www.awakeinamerica.org/ they take donated machines and forward them to folks that need them, they also help folks that can't afford the cost of a sleep study.

[apnez]

Welcome to the wonderful world of Socialism....

[LisaEileen]

My doctor's nurse just called. My doctor will talking to the Medical Director for Medicaid this afternoon to convince him of my need for the machine. She explained things a little to me. My AHI was only 1.2 and it has to be over 15 to qualify. BUT, my thoracic pressure was off the charts without the machine and within normal limits WITH the machine. My sleep was disrupted every few minutes due to the hard time I had breathing. So, even though I don't stop breathing a thousand times a night, I am still having a lot of trouble breathing at night and need machine. She thinks the doctor can convince the Medical Director of my need to get it approved, but if not, I will have to buy one. If that's the case, I'll have to check out that website some of you listed for me to see if I can get a donated one. I just really want to feel better.