getting Ins to pay for going from cpap to apap - suggestions

Refugee · Post by **Refugee** » Tue Mar 06, 2007 9:04 pm

In July of 06 I had my sleep study. I was given a remstar plus cpap machine. I gave up after a couple of weeks of not being able to sleep at all using the machine. In Oct I had surgery to fix my deviated septum. It is just in the last week that I got serious about making this work. I have been able to use my cpap for about a week straight now, although I don't feel any better. During that time I found these forums and have been researching the various equipment available. I really like the idea of having a apap machine. My settings I was given from my sleep study is 7.5 cm H2O.

I've been wondering if this setting is correct, especially since i've had surgery since my sleep study. I like the idea of being able to have the machine adjust during the night, and being able to get the card reader and software to track what happens during the night. We have been renting my machine since July and next month is when we purchase it.

We talked to my insurance today (Blue Cross Blue Shield for federal employees) and they say they need a prescription from my doctor AND a letter from him saying why it is medically necessary to have an apap instead of a regular cpap machine. They also said that all of the money we have been paying monthly towards my current cpap machine and the money they have been paying would not go towards a new apap machine. Any suggestions on how to go about getting an apap?

Wulfman · Post by **Wulfman** » Tue Mar 06, 2007 9:16 pm

Since you may already have a humidifier that will work with the Auto, you might not need another. However, the following URLs are with and without a humidifier. The prices are right.

Den

https://www.cpap.com/productpage-bundle ... undle.html

https://www.cpap.com/productpage-advanced.php?PNum=1607

kent · Post by **kent** » Tue Mar 06, 2007 10:09 pm

Since you have insurance - have your dr order a BiPap Auto - the RX needs to say you failed CPAP. Then your insurance will pay for it.

Wulfman · Post by **Wulfman** » Tue Mar 06, 2007 10:17 pm

kent wrote:Since you have insurance - have your dr order a BiPap Auto - the RX needs to say you failed CPAP. Then your insurance will pay for it.

Not necessarily. And, depending on the inflated prices of the machines at brick & mortar DMEs, the insurance deductibles and the co-pays, the "cash" prices could be MUCH cheaper than going through the insurance.

Den

Linda3032 · Post by **Linda3032** » Tue Mar 06, 2007 10:18 pm

Since you haven't been using your machine, I think you might not have a valid argument for getting an auto. Basically, you haven't been compliant or talked to the doctor about problems. Your current machine shows hours of usage -- but in your case, of non-usage.

Awfully hard to justify a different machine when you haven't "failed" at using the one you have.

You can always purchase one from cpap.com out-of-pocket.

And that said, here is a link for "arguments for getting an auto":

viewtopic.php?p=98351&highlight=apap+doctor#98351

Im2tired · Post by **Im2tired** » Tue Mar 06, 2007 10:50 pm

Every insurance is different. I had my CPAP about a month and went for a follow-up visit. I told my doctor that I felt that I needed an APAP because I have a lot of conditions and I'm on a lot of medication so feel it's unlikely that I would need the same pressure every night. I don't know if he wrote the RX because of my reasoning or because I was crying at the time Anyway that part was relatively easy. I called the DME and they said I would need another sleep study to prove I needed an APAP before my insurance would pay all the extra money for it. I said you have to be kidding, a sleep study would cost more that an APAP. I don't believe that's correct. So I called my insurance and they asked when my sleep study was (it was about 2 months prior) and said they would cover it.
Of course it turned out to be the same cost for the APAP as the CPAP since the billing code is the same. So I faxed the form to the DME and they brought out an APAP for me. I bought Encore Pro myself.

Laurie

Snoredog · Post by **Snoredog** » Wed Mar 07, 2007 1:11 am

[quote="Refugee"]In July of 06 I had my sleep study. I was given a remstar plus cpap machine. I gave up after a couple of weeks of not being able to sleep at all using the machine. In Oct I had surgery to fix my deviated septum. It is just in the last week that I got serious about making this work. I have been able to use my cpap for about a week straight now, although I don't feel any better. During that time I found these forums and have been researching the various equipment available. I really like the idea of having a apap machine. My settings I was given from my sleep study is 7.5 cm H2O.

I've been wondering if this setting is correct, especially since i've had surgery since my sleep study. I like the idea of being able to have the machine adjust during the night, and being able to get the card reader and software to track what happens during the night. We have been renting my machine since July and next month is when we purchase it.

We talked to my insurance today (Blue Cross Blue Shield for federal employees) and they say they need a prescription from my doctor AND a letter from him saying why it is medically necessary to have an apap instead of a regular cpap machine. They also said that all of the money we have been paying monthly towards my current cpap machine and the money they have been paying would not go towards a new apap machine. Any suggestions on how to go about getting an apap?

bluegrassfan · Post by **bluegrassfan** » Wed Mar 07, 2007 5:45 am

Snoredog, that is a very comprehensive answer and it sounds like you know what you are talking about. That's one of my problems, being so new to this (4 wks), I'm not totally sure who knows a lot, versus who just has a lot of opinions. I am betting you know a good bit, so I'm a 8cm, fighting the pressure, but it's getting easier, so it sounds like an apap wouldn't do me any good. I think I have isolated my problem (waking up all night long) to mouth leaks or mouth breathing. I have caught myself pursing my lips and a little air escapes...so I'm thinking about a full face mask. Do you use the Soyala? My DME gave me a chin strap, but it won't stay on my head. tks..didn't mean to steal this post. bob

snoregirl · Post by **snoregirl** » Wed Mar 07, 2007 6:37 am

Bluegrass

Snoredog is correct. Not much benefit for your pressure from an auto. Yes, it would help you easily confirm your titration, but as for any other comfort issues,they just aren't there with your pressure.

One the mouth leaking. Tape (gentle paper tape turned under at the ends so you can grab it and remove it easily), and possibly some kind of chin strap in addition. I like a simple 3 inch ace bandage over the crown of the head and under the chin. Keeps cheek inflation in check too. Full face mask is also an option, but I prefer the tape and ace, others prefer the ff mask.

Sounds like your issues are mainly getting used to the machine/mask. I do think that machine that records data would be a good thing if you either intend to buy the software and card reader and/or take the card to the DME for them to read for you. This would allow you to verify your pressure setting is good.

sleepingBear · Post by **sleepingBear** » Wed Mar 07, 2007 7:16 am

IMHO an APAP can be justifiable for anyone.

Here is a good link with solid reasoning

cpaptalk-articles/reasons-APAP.html

I know I have only been on the hose for a month, but looking at the data from my auto definitely proves to me that an auto is the better equipment. Based on what I have experienced I don't see how a single set pressure can be correct for a person all the time unless your in a comatose state.

When I was sick, my pressure changed, when i was congested my pressure changed. if I had a late and large meal my pressure changed, just changing masks I saw a change. My original titration pressure was 11, over the past 4 weeks my average pressure has been 12, my 90% about 14.

In the end if you really feel 1 set pressure is all you need, then set the machine to cpap instead of apap. but at leats you have the option of doing a self tittration to verify that your pressure is still correct.

Personnally I don't follow the rational that an auto is of no benefit.

snoregirl · Post by **snoregirl** » Wed Mar 07, 2007 11:34 am

Sleeping bear

Your link is great justification for APAP for many people. However most of the article deals with the benefits that APAP can give by letting you use REDUCED pressure some of the time. I totally agree with that as my pressure is 13.

But for this person who started the thread who has a pressure of 7.5, there is very very little reduction in pressure possible, thereby making all those reasons not very useful.

I would be the last person to say I wouldn't want an APAP. I love it and all the flexibility it gives, but in justifying it to an insurance company for a person with a titratated pressure of 7.5, it would be very hard to do, as most of us don't want to run under at least 6.0 to begin with for comfort and to exhaust the mask properly.

Guest · Post by **Guest** » Wed Mar 07, 2007 1:11 pm

In most cases, it is NOT justification for an Auto for the insurance company. They pay the same for an Auto as they do for a straight CPAP. It is the DME who plants their feet regarding an Auto. Since they get paid the same for a straight CPAP as they do for an Auto, an Auto cuts into their profit margin - so you will almost always need proof of MEDICAL NECESSITY if your DME doesn't want to provide an Auto.

snoregirl · Post by **snoregirl** » Wed Mar 07, 2007 2:16 pm

Slinky,

Good point and you are probably right in your comment about "most" cases....

In mine however, my insurance company was as firm in their belief that I did not "need" an apap as the DME was. My insurance policy actually has a clause that defines "premium machines" and the fact that they will not cover them -- not even apply money that they would have spent for a "normal" machine towards the "premium" machine. They assigned an insurance company doctor to review my case and he, without meeting me or any discussion on the phone, unilaterally decided what he thought I "needed". Very sad.

So, they are all different, and I suspect from what I have read here that my insurance company is more the exception rather than the norm.

sleepingBear · Post by **sleepingBear** » Wed Mar 07, 2007 4:47 pm

Snoregirl,

Running at a lower pressure most of the night is only part of the reasoning for an APAP.

Your missing the aspect of a persons pressure needs changing from one night to the next for various reasons.

Just the simple act of changing your sleeping position can cause you to need a higher pressure to overcome an Apnea. An APAP can compensate for this where as a CPAP will do nothing.

Personally I don't see how a single nights study can accurately predict what pressure you would need for the rest of your life. Just because 7.5 worked that night does not mean it will be enough tonight.

My titration was 11, I rarely see my auto that low, if I were to accept a CPAP my therapy would be very poor.

Since the original poster stated that they have been using the CPAP for the past week and do not feel it's helping would indicate to me that it's not helping and the most probably cause would be that her pressure is to low. An APAP would show this in a single night.

There are countries that issue nothing but APAP's becuase of the value added and there are studies that show that the long term cost of treatment is less when someone is placed on an APAP.

Personally I see no value to placing someone on a straight CPAP when an APAP can fill the need and provide the ability to adjust automatically, and if you don't like the changing pressure it can be set to CPAP.

What is the cost difference between an APAP and CPAP? a little more than $100.00

sleepinginseattle · Post by **sleepinginseattle** » Wed Mar 07, 2007 5:02 pm

sleepingBear,

I'd pay a hundred dollars too for the APAP if you could prove any of the reasons you've stated for APAP superiority.

The truth of the matter is most people on CPAP (or APAP therapy) fall asleep. While they're asleep the constant pressure of CPAP equipment stops the apnea events. There is no reason to believe that you'll receive any added benefit from an APAP device. There's no evidence that APAP users have a higher level of compliance or that they benefit from a better quality of treatment.

If you're arguing that people have different needs because of body position that's rationalizing the auto-adjusting capability of an APAP where additional features are not required. There is no evidence to suggest that patients, in general, may need a lower pressure than was determined in the PSG titration or that there might be a long-term therapeutic benefit to lower pressure.

Many on this board support a broad advocacy of self-titration versus PSG titration. The facts remain, there is no evidence to support the conclusion that self-titration is more effective than PSG titration.

Personally, I see no value in spending extra for APAP equipment. CPAP equipment provides all the benefits without added cost or complexity.

Just my $.02.

getting Ins to pay for going from cpap to apap - suggestions

getting Ins to pay for going from cpap to apap - suggestions

Re: getting Ins to pay for going from cpap to apap - suggest