My time (for xPAP) has come! (Slinky, Rested Gal? Help!)

k8e · Post by **k8e** » Thu May 08, 2008 4:24 pm

Here is the link to the Blue Cross of CA (now Anthem Blue Cross) Clinical Utilization Management documents database page. It should give you the exact policy regarding what is considered medically necessary.

http://www.anthem.com/wps/portal/ca/cul ... l=Overview
http://www.anthem.com/ca/medicalpolicies/search.html (typing in "CPAP" returns about a dozen results)

Here is what Clinical UM CG-DME-32 says about the medical necessity for APAP:

Auto-CPAP (APAP) is considered medically necessary as a second or third line alternative therapy for obstructive sleep apnea when documentation of the following is available:

1. The level of fixed CPAP required is at least 10cms H2O as evidenced by an in- laboratory, technician-attended CPAP titration during polysomnography; AND
2. The patient is intolerant of high fixed CPAP pressures (>10cms H2O) despite appropriate patient education and interventions to improve patient comfort and compliance. These interventions should include:
* The use of a topical nasal corticosteroid spray or anticholinergic spray if nasal complaints are significant; and
* Changes made by a nurse or technician, in consultation with the attending physician, to the CPAP circuit or mask, using different nose masks, face masks, nasal pillows or head harnesses as appropriate to achieve maximum patient comfort.

I have Aetna, not Blue Cross, but they have similar documents, called Clinical Policy Bulletins, that define medical necessity.

I have found that it's better to rely on the written policy than what the representatives tell me verbally. Hope this helps!

goose · Post by **goose** » Thu May 08, 2008 4:27 pm

Wow!!! What a convoluted bucket of crap!!!
You can almost get a nice APAP machine online for the $400 difference.
Note that the price listed is the "Required Minimum Advertised Price"....The manufacturer, in their infinite wisdom and greed, has required the online vendors to put that number on their listings. Call them to find out what the "real price" will be.....wink, wink, nudge, nudge......
Stupid game to play, but it's all a game anymore and you're already in the middle of one.....

You've really done a great job!!!! Keep at it!!!

cheers
goose

k8e · Post by **k8e** » Thu May 08, 2008 4:49 pm

schleima, FYI, my BF has the Resmed S8 Elite, the version right before yours (the S8 Elite II which just became available a few weeks ago) and it is a good machine even though it is not an Auto. The S8II series has some nice feature upgrades (improved comfort features, quieter motor, and finally, USB connectivity!) so as CPAP goes, you probably did quite well.

BF will need APAP after all due to gastric insufflation (too much air being forced into the stomach), and we are trying to get him the Resmed S8 II version of the Autoset. Our insurance, like yours, considers APAP medically necessary only after failing CPAP, but then will pay for it at the full benefit amount (no "upgrade" surcharge). I am thinking the reason for you having to pay the difference for APAP is that the upgrade is not *yet* considered medically necessary (see the clinical UM I posted earlier in this thread).

schleima · Post by **schleima** » Thu May 08, 2008 4:56 pm

k8e wrote:Here is what Clinical UM CG-DME-32 says about the medical necessity for APAP:

Auto-CPAP (APAP) is considered medically necessary as a second or third line alternative therapy for obstructive sleep apnea when documentation of the following is available:

1. The level of fixed CPAP required is at least 10cms H2O as evidenced by an in- laboratory, technician-attended CPAP titration during polysomnography; AND
2. The patient is intolerant of high fixed CPAP pressures (>10cms H2O) despite appropriate patient education and interventions to improve patient comfort and compliance. These interventions should include:
* The use of a topical nasal corticosteroid spray or anticholinergic spray if nasal complaints are significant; and
* Changes made by a nurse or technician, in consultation with the attending physician, to the CPAP circuit or mask, using different nose masks, face masks, nasal pillows or head harnesses as appropriate to achieve maximum patient comfort.

I am afraid that I do not meet the criteria for APAP under these guidelines, as my apnea is moderate to mild (my titration is 9cms). But I am just happy to get a high-end cpap with data and not a bucket that blows air.

Thanks k8e for your research on my behalf. I'm fine to start with the CPAP, as long as its a good quality one, and work up to APAP if my titration requirements exceed 10cms. I was just hoping to head it off at the pass and get the best one right off the bat, but if my insurance won't cover it, then what can I do? I think I've made out pretty well, regardless.

Slinky · Post by **Slinky** » Thu May 08, 2008 5:32 pm

I think that DME supplier is a sheister. And they are always gonna be a headache. NO way would I want to deal w/them for the rest of my CPAP life!! Its gonna be one continuous battle. If your insurance gives the option of other local DME suppliers check them out first!

I'd check to see what other local DME suppliers your BC/BS is contracted w/and what they will provide you.

Meanwhile, you have a legal right to that script. It is a part of your medical records. Maybe they need to be reminded of HIPAA!!! A WRITTEN request for the script WITH the HIPAA reminder, sent via Certified Mail, Return Receipt Requested. If it takes a SECOND WRITTEN reminder, that one is clearly cc'd to the state licensing board. When those return receipts reach yer grubby little mitts you have them by the "short hairs".

All that being said: my first CPAP was a Resmed S8 Elite and I LOVE it! I got the "auto fever" and self-purchased the Resmed S8 AutoSet Vantage and LOVED it. But since I had the "capped rental" compliance for the Elite I didn't use the Vantage except when traveling. I have COPD and was called back in for a bi-level titration and I opted for the Resmed VPAP Auto which is in the S8 body and uses the Humidaire 3i humidifier and I'm pretty sure is an S8 II (it has the EasyBreathe technology is why I think that).

I'd be happy w/the Resmed S8 II Elite if I were you. There comes a time it is just easier to compromise.

But I'd still check w/any other local DME supplier options your insurance allows and if they'll provide you w/the S8 Elite II and have a lenient mask exchange policy and are more pleasant I'd go w/them instead.

k8e · Post by **k8e** » Thu May 08, 2008 5:32 pm

schleima,

Another consideration is rent vs. purchase. Most insurance will pay for a purchase or for 10-12 months of rental, and after that, you own the machine, but they push rental, understandably, because of the low success rate with CPAP.

There are some advantages to purchase vs renting:
- All of your out of pocket goes to your deductible for the current plan year. If your 10-12 months of rental wraps around to the next plan year, you may have to pay more out of pocket.
- If you purchase, you can get a brand new machine. I would expect a used machine if rental, although you may be able to negotiate this with the DME if they are nice. In your case, the S8 Elite II is a new model, so you will surely get a new or nearly-new machine regardless, as long as they give you the S8 Elite II and not the previous model S8 Elite. (S8 Elite still a very good machine but the S8 Elite II has some very desirable feature upgrades.)
- If you purchase outright and submit for reimbursement, you can put it on your credit card and take advantage of any extended warranty benefits you may have with your credit card (Amex doubles the warranty up to 1 year, so do certain MasterCard cards).

This can get a little more complicated if you end up needing to go to APAP later, but your clinical UMs should spell out the policy.

I have sent you a PM.

rested gal · Post by **rested gal** » Fri May 09, 2008 9:29 am

schleima wrote:I think I've made out pretty well, regardless.

Even beyond the machine itself, I think you've done MUCH better than "pretty well", schleima. Regarding the doctor's high and mighty behavior over your request for a copy of your Rx, you got a LOT accomplished:

schleima wrote:First the doctor replied via email. Then I replied back to her, and then the clinical admin director called me.

----

Oh, and in news regarding my medical records, I just got a call from the nice lady who promised to get me my medical records and prescription

Excellent!

I wouldn't be surprised if the clinical admin director gave the uppity doctor a well deserved little chewing out behind the scenes, over how the doctor was dealing with your request for a copy of your Rx.

schleima · Post by **schleima** » Fri May 09, 2008 11:12 am

OK, here's two more email updates from the doc.... one came yesterday and got held up in my spam filter, so I didn't read either of them until just now.

My main concern as a Physician is the safe and proper care of my Patients

As I recall in our phone conversations, I mainly deny

1) Sending you the Prescription for the CPAP Machine that you found in the website because I do not think that is proper care.

2) Sending you prematurely the prescription to the vendor of the Durable Medical Equipment (DME) company, because different insurance has contract with different company ,the reimbursement for varies and your co-payment varies.

3) At NO time I denied your right to access to your other records. In fact ,during your clinical consultation with me I said in my note dated Feb 27 2008 that you have a cc copy of that note and that you had the right to call me on Fridays 12-2 pm for questions, in addition for follow up call Lauren for follow up..

If you still want to terminate our Patient Physician relatiomship,it is your right too,. Since I have to be compliant , you need to officially sign a release of all the records from the UCLA Medical Records, Medical correspondence

-----------------

The Vendor Air care office called me yesterday afternoon that they checked and your insurance SAG is in network .She left message in your voice mail three times to set up appointment to set up Nasal CPAP as prescribed by me, so far has not heard from you. Should you decide to go with them, then I can send you the prescription that I sent them on May 2,2008..During your meeting with them, you can bring up the issue of your website research of the model you wanted and have them advise you the pros and cons éclat least you get a professional service to help you .Please call me if you want me to fax you that prescription..

------------------

To which I replied this morning:

The problem all along is that you did not LISTEN to me. I never wanted to order a CPAP unsupervised from an internet vendor. My intention all along was to take your prescription to my endocrinologist, who always answers all of my therapy questions and, most importantly, LISTENS to his patients without rushing them off the phone. I wanted to tell you this but you pushed me off the phone before I could even explain this.

I recall clearly that the moment I mentioned that I had done some internet research, you immediately began talking over me. This is where the problem began.

What is even more problematic is that you feel a medical vendor has proprietary rights to MY medical information, which certainly has huge ethical and legal implications, to which you seem oblivious.

I no longer wish to carry on this conversation. If I don’t receive my prescription within a week I will be reporting you to the California medical board for violating HIPAA. Consider this email my digital signature for release of record purposes.
---------------

NightHawkeye · Post by **NightHawkeye** » Fri May 09, 2008 1:03 pm

Amazing, Schleima. apparently, she's been right all along (according to her).

schleima's physician wrote:As I recall in our phone conversations, I mainly deny

1) Sending you the Prescription for the CPAP Machine that you found in the website because I do not think that is proper care.

Hmmm ..., now just why would she care where you get your equipment from?

schleima's physician wrote:As I recall in our phone conversations, I mainly deny

2) Sending you prematurely the prescription to the vendor of the Durable Medical Equipment (DME) company, because different insurance has contract with different company ,the reimbursement for varies and your co-payment varies.

It would have been a simple matter to inform you that she only knew about reimbursement for one specific company ...

schleima's physician wrote:If you still want to terminate our Patient Physician relatiomship,it is your right too,. Since I have to be compliant , you need to officially sign a release of all the records from the UCLA Medical Records, Medical correspondence

Hey, didn't you already do that?

schleima's physician wrote:The Vendor Air care office called me yesterday afternoon that they checked and your insurance SAG is in network .She left message in your voice mail three times to set up appointment to set up Nasal CPAP as prescribed by me, so far has not heard from you. Should you decide to go with them, then I can send you the prescription that I sent them on May 2,2008..During your meeting with them, you can bring up the issue of your website research of the model you wanted and have them advise you the pros and cons éclat least you get a professional service to help you .Please call me if you want me to fax you that prescription..

LOL. Don't that beat all ... She's still trying to force you through AirCare ... I can't believe she really said this ... Taken at face value she'll only release the prescription to you, if you go with AirCare. Maybe that's a language thing, but since she still hasn't released the prescription to you, call me skeptical ...

There's more here than meets the eye. A lot more would be my guess ...

Regards,
Bill (whose worst problem online was less than a week's wait for a warranty replacement)

schleima · Post by **schleima** » Fri May 09, 2008 1:07 pm

And one more update... this time they finally faxed the prescription!!!!

Alleluia!

My final email:

The problem all along is that you did not LISTEN to me. I never wanted to order a CPAP unsupervised from an internet vendor. My intention all along was to take your prescription to my endocrinologist, who always answers all of my therapy questions and, most importantly, LISTENS to his patients without rushing them off the phone. I wanted to tell you this but you pushed me off the phone before I could even explain this.

I recall clearly that the moment I mentioned that I had done some internet research, you immediately began talking over me. This is where the problem began.

What is even more problematic is that you feel a medical vendor has proprietary rights to MY medical information, which certainly has huge ethical and legal implications, to which you seem oblivious.

I no longer wish to carry on this conversation. If I don’t receive my prescription within a week I will be reporting you to the California medical board for violating HIPAA. Consider this email my digital signature for release of record purposes.

Her reply:

At this point it is ALl subjective recall.The facts stand that I sent the prescription to the Vendor.The fact that I did cc you the copy of your consultation report.I will fax your prescription to your number stated below. also per your phone request you want the CPAP test of April 18 2008 .Please acknowledege that you receive them.

-------------------------

Bottom line... I now have my prescription, which by the way reads as follows:

-CPAP (there is no box to check for APAP... only "sleep study", "CPAP", "Bi-Level" or "Bi-Level w/backup rate" and "Heated Humidifier")
-Best mask interface as patient prefers
-Nasal 9cm H2O Ramp 20 minutes

I suppose if I really wanted to draw this out, I could have my endo now write a prescription for CPAP with a pressure range, and shop around to DMEs. But eh, I'm kind of tired of fighting this battle. And as I said (and others confirmed) I'll likely be very happy with my Resmed Elite 2.

What a hellish experience this has been... thanks to everyone for your encouragement, support and help.

goose · Post by **goose** » Fri May 09, 2008 1:37 pm

Hey Schleima -- that's great!!! You can save the script re-write for a later date if you feel you need it. Understand being tired of the battle!!!

When you get your machine and mask, let us know how you like it, how it's going etc.

take care
cheers
goose

Slinky · Post by **Slinky** » Fri May 09, 2008 3:38 pm

Did you notice what that "dipchit" wrote????

... "CPAP", "Bi-Level" or "Bi-Level w/backup rate" and "Heated Humidifier") ...

I would TREASURE that script!! File it away nice and safe. It won't fly w/a local DME supplier but it would w/an online DME supplier.

I think I can understand why she would prefer you get your equipment from "Brian" at AirCare. He's probably very patient w/her ignorance and helps hand walk her thru the proper procedure and necessities. She is most likely reluctant to let other DME suppliers know how "rank" she is! Who in their right mind wants to flaunt their own ignorance all over town? It certainly appears to be much more than just a language problem!!!!

schleima · Post by **schleima** » Fri May 09, 2008 4:15 pm

[slinky quote] ... "CPAP", "Bi-Level" or "Bi-Level w/backup rate" and "Heated Humidifier") ... [/quote]

Just to clarify-- the Rx has 4 checkboxes.... one says CPAP, one says Bi-Level, one says Bi-Level w/backup rate and the last checkbox is "Heated Humidifier"

She checked CPAP and Heated Humidifier. My point was that there is no spot on the form for her to check off APAP.

Slinky · Post by **Slinky** » Fri May 09, 2008 6:19 pm

That's cause, according to HCPCS billing codes APAPs "are" CPAPs.

But, yeah, I did miss that distinction of marked/unmarked box choices. Ah, well, can't win 'em all.

ozij · Post by **ozij** » Fri May 09, 2008 9:01 pm

Very good, schleima.
And I think that last letter was dictated to her by someone else. The language is mostly too formal and different from her other communications. Somebody out there was not oblivious to the "ethical and legal implications" you mentioned.

If she won't learn from that experience, I have no doubt UCLA will...
O.