ASV & Insurance Claims

[BrianinTN]

I hope I'm being overly concerned here, but I thought I'd go ahead and solicit some opinions and experiences from you folks. Let me start off giving you an abbreviated recap of where I am and how I've gotten here, and then explain my question.

I had my first and second sleep studies last summer for diagnosis and CPAP titration, respectively. The CPAP titration study revealed centrals, but my doctor went ahead and prescribed a CPAP with the hope that the centrals would go away with time. My insurance bought the CPAP machine outright.

The centrals did not go away. I went back to see my doc a couple months ago, showing him the data from home, and he sent me back for a third sleep study, this time for BiPAP titration. They managed to stabilizing me with a low AHI for the final three hours on a BiPAP S/T, and insurance purchased my second ventilation machine as a result with no problem.

Unfortunately, my home experience on the BiPAP S/T was far from ideal. Not only did I show a high AHI (mid 30s most of the time), but I felt awful after using it. I was able to tweak my own pressures to something not dictated in my titration study (a lower EPAP) which improved the home reading on the AHI, but I still didn't feel good, and there were only two days of data on that setting before I had my doctor's appointment.

Based on my symptoms, my doctor sent me in for an ASV titration. The ASV was great. I woke up feeling kind of "wow" and the AHI was below 1. My doc prescribed an ASV, and for the past two weeks, I've been waiting on my doc/DME/whoever to set this up. People seem not to move too quickly around here, but I won't digress....

Here's my issue: My insurance buys machines outright, and my DME won't accept returns once you take a new machine home. I'm paranoid to death about my DME sending me home with an ASV, BlueCross rejecting the claim, and me being stuck with an $8000 bill. My concern stems from what seems to be a "missing link" of sorts with regard to the insurance claims. In sleep study #3, they had me titrated at what appeared to be OK settings on a BiPAP S/T. In sleep study #4, they jumped directly to an ASV titration. There was no time IN THE LAB spent trying to "prove" that a standard BiPAP S/T wasn't indeed working. What I'm afraid of is that when the musical chairs sequence stops, BlueCross will say, "well, the number showed you fine on the BiPAP S/T so we won't cover an ASV" and I'm stuck with the bill.

What makes my situation unique and somewhat difficult is that my insurance does cover outright purchase of these machines. (As an aside, I feel like purchasing them without any home experience to prove both efficacy and compliance seemed kind of stupid -- had they had such a policy, which most patients find to be an inconvenience, all of this could have been averted.) BlueCross has now bought me two machines. Buying a third seems potentially problematic.

I've been considering telling my DME to file the claim with insurance but for me not to take possession until the claim has been processed and approved. That adds (based on the amount of time required to process my BiPAP S/T claim) at least 5 weeks to the process, but seems reasonable as a precaution not to get stuck with a massive bill. I hate to do this though, as it delays my treatment (which I want to begin before I tackle my PLMD problem). But given that I can get a used ASV machine for a quarter or less of the retail DME cost, I'd hate to be stuck with a full retail bill.

In light of the above, does anyone have any words of insight or wisdom? Congratulations to anyone making it this far. I probably could have worded this more succinctly but thought the details might be of use to the most savvy of readers.

[fuzzy96]

a lot of times like for surgeries and other procedures, the doctor can submit the information and the insurance will "pre-certify" meaning that they will cover if nothing changes from the submitted information.
call your insurance (and get a name) and find out what procedures they have for such. they may even be able to fax the info to you dr.

good luck

[Janknitz]

I don't know if it will help put your mind at ease, but the billing codes for the two machines are different, so at least your insurance company won't "read" it as a duplicate item.

But, it has to be medically justified. Philips Respironics has some resources here: http://www.healthcare.philips.com/main/ ... efault.wpd which include links for wording for certificates of medical necessity and they even operate a hotline to help DME's and physicians get reimbursement. You should share that link with your doctor and DME (DME may already know about it). The key is the doctor's documentation must support the medical necessity, and your diagnosis code and the billing codes for the machine must be correct.

I think your plan to get pre-approval is a good one, unless the DME will certify IN WRITING that they will take the machine back and not charge you if the insurance doesn't come through (don't take their verbal word for it!).

Good luck with that.

[-SWS]

Brian, I don't think your doctor will have a difficult time proving medical necessity for ASV. If you do buy an ASV used, be sure to get the same model that worked well for you during the PSG.

You might find something useful in this search:
http://www.google.com/search?q=%22medic ... =firefox-a

[BrianinTN]

fuzzy96: Yeah, I'd talked to a woman at BCBS. She indicated that since there's no pre-approval process for them, there only viable option is to have the DME submit a ghost claim of sorts -- basically going through the motions before I take possession of the machine.

Janknitz: I had a separate thread here about my problems with the BiPAP S/T (viewtopic.php?f=1&t=61719&p=587658#p587658), and SWS had brought up the usual Medicare guidelines for covering ASVs. I suppose this is what makes me nervous -- that they haven't shown in the lab yet that the BiPAP S/T fails. It's all from my home data and self-reported symptoms.

SWS: Thanks, yeah, I'd done some googling myself over the past couple weeks. I was surprised that I didn't turn up anyone quite in my situation; while I know a small percent of users fall into my category, I'd think I'd have found at least a few accounts similar to mine. Honestly, from reading your responses to my threads and others, it's obvious you're savvy, so tell me straight-up: do you think I'm being paranoid? would you just go ahead and take the ASV home and believe that insurance will work itself out? I did talk to my doc last week and told him what BCBS had indicated to me -- that they would take a "pretty hard look" at the claim given that they've already shelled out for two machines. Do you think the doctor's letter really will satisfy the requirements of medical necessity by insurance guidelines? The language in some of the various documents seems ambiguous to my untrained eye. For example, lines like "If central sleep apnea requires pressure therapy and is not adequately controlled with CPAP or standard bilevel PAP, then bilevel PAP with a back-up rate or a servocontroller feature will be covered upon a demonstration of effectiveness" suggest that coverage will be provided. However, other lines make specific reference to PSG data, and nothing I've found has ever hinted at my specific situation (migrating from a BiPAP S/T to an ASV when the BiPAP was shown in the PSG to work).

[Mr Bill]

There is yet another possibility not mentioned. My insurance provider (Cover Colorado) choose not to purchase such an expensive unit and choose to rent it to me instead. I don't even know if its rent to own or lease. On the timing side, I went in on a Monday with my RX after the sleep lab the preceding Friday. My DME did not stock such an expensive unit and ordered it. I had it by Friday of that same week. I know you can get these at CPAP.com for $5800 and used on line for much less (there was a post yesterday). My DME marked it up to $8750 for the whole setup (unit, humidifier, hose, mask, carrying case, manuals, filters). Cover Colorado chooses to rent it, so I am paying $121/month.

[Breathe Jimbo]

I would be concerned about a potentially uncovered, $8,000 bill.

[BrianinTN]

After two weeks in limbo, I finally got an answer. Figures it would come the day after I post. The DME is going to take back the BiPAP S/T and do an even swap for a new ASV, including humidifier. Insurance won't even be involved. ::phew:: I'm not sure why the DME is working it this way, but I'm happy about it! I'm out of the country now, so I won't get to swap it out until a week from Monday, but at least I have a little countdown to finally getting some decent sleep. Yay! Thanks for the input, all.

[tonycog]

After two weeks in limbo, I finally got an answer. Figures it would come the day after I post. The DME is going to take back the BiPAP S/T and do an even swap for a new ASV, including humidifier. Insurance won't even be involved. ::phew:: I'm not sure why the DME is working it this way, but I'm happy about it! I'm out of the country now, so I won't get to swap it out until a week from Monday, but at least I have a little countdown to finally getting some decent sleep. Yay! Thanks for the input, all.

That's a very good deal. Good for you, and props to the DME for taking care of their customer.