insurance will not pay for apap

[stillLearning]

I was told my insurance will not pay for APAP. Is this true?

[stillLearning]

My DME told me my insurance would not pay for APAP. Very confused.

[wabmorgan]

MOst will pay(ie rent) a CPAP but not an APAP.

[rested gal]

In most cases, it's probably the home health care store (the "DME") that doesn't want to let you have an autopap instead of a straight cpap. Insurance is going to reimburse them the same amount of money whether you are given a cpap machine or an autopap machine, so it really makes no difference to the insurance company. The billing code is the same for either of those two machines. Both are billed as "cpap". An autopap is considered to be a cpap machine....an auto-titrating cpap, but a CPAP all the same...for insurance billing purposes. An autopap costs the DME more to purchase. There's less profit for the DME if the DME gives you an auto-titrating CPAP instead of a straight CPAP.

[snoregirl]

I have to agree with Rested gal.

My insurance also said this (APAP deluxe machine and not covered), but I managed to get the DME to give me an APAP (wasn't easy) and the insurance has been paying the code billed. Same code so Insurance doesn't know or care.

If doctor prescribes APAP, insist on it from DME. You may lose, but it is also possible to win.

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CPAPopedia Keywords Contained In This Post (Click For Definition): DME, APAP

[Guest]

Or just don't use a local DME, instead use an online place such as cpap.com. Your doctorbs cannot force you to use a certain DME.

[RedThunder94]

the billing code is the same for a cpap and an apap, if the dme does not want to give you what the doctor prescribed than go to another one that will, all it took for me to get my insurance to pay was a phone call, they still are paying since it is a rent to own deal, no biggie, i just pay my 18.99 a month and wait till january to pay the whole 94 dollars there after monthly till my 300 dollar deductable is met. lol.

[KansasRT]

Just make sure that your Dr writes a script for an auto-titrating CPAP. A DME company cannot alter a script to include an Auto titrating machine unless the Dr includes it on the script.

[jrgood27]

My insurance documentation said APAP wouldn't be covered until CPAP was tried first.

I called them and the rep said I needed a letter of medical necessity from my sleep specialist to get an APAP at all. I guess my doc sent this to the DME b/c the APAP was supplied to me and covered no problemo.

Try to work every angle you can.

Jenny

[Linda3032]

All insurance companies have different requirements - our experiences will not be the same as yours. That said here are my thoughts:

Your insurance company would have to pay if your doctor wrote a prescription for an apap.

Your insurance company might require you to try cpap first.

Does your insurance company require you to rent first, and then buy? It might be easier to "switch out" machines if that's the case. Depending on how nice your DME is.

If you start on a cpap, and complain, complain, complain, it might be easier to get an auto. (it's unfortunate that we have to manipulate others to get what we want/need/deserve). Complaints should be to your doctor - the DME and insurance will have to follow his instructions. But it won't hurt to complain to the DME also.

Complaints might be:

Too much pressure.
Too little pressure.
Air in stomach.
Can't breath.
(others can chime in here).

Good Luck

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CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, DME, Prescription, auto, APAP

[Linda3032]

And check with your insurance company to see if the DME has lied to you. Also, DO NOT fall the song and dance that an auto is going to cost you extra money. This is something that many DMEs try to pull - to get more money from you. If he tries it, find another DME. Or tell him you will find another one if he starts singing and dancing.

[Casca]

[quote="stillLearning"]I was told my insurance will not pay for APAP. Is this true?

[OSAGuy]

I had no problem with my insurance paying for an APAP as prescribed. My Dr. specifically prescribed an APAP. The insurance co. (Blue Cross) did ask for a letter of medical necessity, which my Dr. included with the prescription.

[snoregirl]

You were lucky. My doc provided a letter of medical necessity and the insurance doc still said it wasn't necessary.

Someone commented way up after my first post (of My personal experience) that no one is forcing "you" to use a certain DME.

True, but I was getting the same story from multiple DME's and my insurance was denying it too.

I did manage to get it by pressuring the DME, but the point is you need to work at it sometimes. Linda is right, Insurance doesn't know or care as long as the billing code is cpap. But if the insurance calls it deluxe then that gives the DME leverage in denying it.

If your insurance will cover without a hassle, and the DME fills the prescription as written with no hassle GREAT!!

But if not, there are a number of issues ranging from the "must try CPAP first -- which by the way sometimes locks you into a DME and takes away any leverage you might have had in the first place-- to the Deluxe equipment insurance co argument that must be overcome (for some of us).

[Ric]

I was told my insurance will not pay for APAP. Is this true?

That has got to be the biggest and most common deception by shady DMEs that is heard on this forum. The strategy is to leave you with the feeling that your insurance won't pay a dime for an APAP, leaving you holding the entire bill.

NOT TRUE !!!

Worst case, as RG and others have pointed out is that virtually all third-party payors will reimburse at least the same amount as they will for a straight CPAP. But many CPAP/APAP customers don't learn that subtle "half-truth" until they have already signed a purchase or rental agreement. And then it's usually too late. And a lot of people are hurt and angry and feel they have been deceived by people they have trusted. Which has a whole lot to do with why many DMEs have earned a bad rep. It also has a whole lot to do with why the long-term compliance rate is a dismal <50%, and why a large percentage of apnea sufferers continue to experience less than optimal therapy, or none at all. And it's why many on this forum are trying our best to warn the prospective CPAP/APAP users of what they are up against and what are their options.

I have a high regard for DMEs that put their cards on the table and tell you your ACTUAL options and work with you to get the equipment that is best for YOU, and to follow up and make sure it's doing it's job and that you are getting treated properly. Those are exceptional. Really, you have LOT'S of choices. Don't settle for dumb equipment, just because your DME shows you his/her sad sad brown/blue eyes and recites the all-too familiar line about how sorrrrrrrrry they are about how your insurance will not pay for what your doctor prescribed. There is a DME somewhere on this planet that will work with your insurance and get you EGGZAKTILLY what you need and what is best for YOU, the customer. The others should not be rewarded.

-Ric

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