how to convince insurance to pay for APAP instead of CPAP

snoregirl · Post by **snoregirl** » Thu Sep 28, 2006 10:18 am

Nothing wrong with being the anal geek type. A lot here are.

Guest seems to be a "take the machine and be happy you got it" approach.

I don't agree.

You have to figure out what you would gain from APAP and if it is worth it in either fight or out of pocket cost to get one.

I for one get lower pressure much of the night from APAP. My titrated pressure is 13 and I run at 10 much of the night. I can feel a HUGE difference in leaks at 10 vs. 13. To me this is VERY RELEVANT in my usage and compliance and ability to have treatment and not wake up (which would defeat the purpose of CPAP) with a leaky mask.

Other reasons are less pressure = less irritation to my ears which are stuffy from CPAP.

Positional sleeping changes pressure requirements -- sleeping on back vs. side...). Any questions about the accuracy of your sleep study would be addressed with APAP.

Ability of APAP to easily adjusting to changed requirements (possible weight loss, just plain changing anatomy and needs through aging) would be yet another reason for APAP. Just staying away from another sleep study could save you more than the cost of a APAP out of pocket in the future.

SO, that said. If you are fine with the Pro2 go ahead. BUT make sure you are not paying more than $700 copay or you could just as well buy APAP cash online. Or mid $500 for Pro2 or you might as well not have insurance.

As for a national company like Apria (I got mine from Apria), yes they are a national outfit, but they have local presence in towns across america, therefore they would in my opinion be considered a "local" DME" where you can try stuff on etc.

Before you think that I love Apria, don't. I dealt with them because my insurance was ok there and the price out of my pocket (copay) was ok ($280 for Remstar Auto) AND they gave me my APAP (with prescription from doc) after a series of phone conversations in which I repeatedly said "I want the APAP my doc prescribed for me". I was lucky to have a doc who wrote the script for APAP when I asked. Apria and any other local DME will probably not fill a CPAP prescription with APAP. But it is transparent to your insurance co. E0601 (CPAP or APAP).

On the issue of insurance company not paying for APAP. Somewhat true if your company told you that. Mine would not even apply the base $ to a "deluxe" unit. So essentially I could have base model or none. BUT when the paperwork for reimbursement from the DME went in, E0601, they paid it. No one there looked at the model or anything since if they had it said APAP and they should have denied it. They paid it.

No matter what you do, get that prescription and sleep study report in you files at home. If YOU CHOOSE to do APAP now or at a later time the prescription is good as written for CPAP online.

I am wary of docs who sell equipment or are associated with sleep labs. I think there is too much room for conflict of interest. I am also wary of docs who don't like patients discussing their care or asking for their paperwork. I will repeat my x-ray story again. I wanted my xrays for my leg from a hospital. The hospital staff told me I couldn't have them. I knew better. My sister is a hospital nurse, and told me it is common for them to say this since they don't want you to have them. She told me go in there and insist. I did and it didn't take much for them to cave when they realized I wasn't the average uninformed person with no guts who knew that those x-rays were MINE and I was entitled to a copy. Same here. You are entitled to a copy of your prescription to fill as you will. You let the doc know you want it and want it now, you will most likely get it. In addition this is a sleep doc. Do you think you will be seeing him/her on a regular basis now that the study is done? Do you care if he thinks you are pushy? I certainly wouldn't. With the kind of parental relationship you seem to have with this doc I would take my prescription (and maybe my machine if I was happy with CPAP and the price was right) and say goodbye.

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

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

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

Guest · Post by **Guest** » Thu Sep 28, 2006 10:35 am

snoregirl wrote:Guest seems to be a "take the machine and be happy you got it" approach.

Not at all. I believe strongly in finding the most effective solution at the lowest cost.

snoregirl wrote:I for one get lower pressure much of the night from APAP. My titrated pressure is 13 and I run at 10 much of the night. I can feel a HUGE difference in leaks at 10 vs. 13. To me this is VERY RELEVANT in my usage and compliance and ability to have treatment and not wake up (which would defeat the purpose of CPAP) with a leaky mask.

Which is exactly my point. If you noticed, in my previous post I quoted SVH from her other thread where she listed some of the results from her Titration report:
"Also - due to the extremely low airflow rate needed to keep an airway open in your case (<5cm = AHI of 3)" Obviously, she will barely even be able to GET a lower airflow since cpaps only go to 4cm. Not to mention the fact that very nearly everyone who ever commented on low pressures here has stated they feel like they are suffocating at about 6cm or less. So one of the largest benefits of apap - lower pressures - goes right out the window in this case. Going by the previous thread SVH has, the events were in all positions so another major benefit of apap is out the window.
Hence my statement that really a cpap will more than solve the OSA problems and the smart card in the pro2 will satisfy the inner geek in many of us.

SelfSeeker · Post by **SelfSeeker** » Thu Sep 28, 2006 10:43 am

What data will be collected with the Pro 2 vs the Pro M.

svh, what data would you like to have?

Which machine is cable of recording the data you want to look at?

svh · Post by **svh** » Thu Sep 28, 2006 10:48 am

PLEASE correct me if I'm wrong, but don't they both collect the same data? My understanding, from looking on cpap.com, is that the Pro M series is just smaller than the Pro 2 series. Yes? No?

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Wulfman · Post by **Wulfman** » Thu Sep 28, 2006 10:52 am

Yes, their data recording is the same.

Den

snoregirl · Post by **snoregirl** » Thu Sep 28, 2006 1:13 pm

Guest,

The pressure may be low now, but that doesn't mean it will continue to be that low in the future. After all she didn't need any pressure not that long ago. Who is to say that her needs couldn't become significantly higher in the next couple of years. An APAP would make self titration easier as well as have added beneifts should she need to use a higher pressure.

She asked what is good about APAP. All I did was to tell her what that was. It is all about options. SHE needs to decide what SHE is happy with. Not the doc.

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

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

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

Snoredog · Post by **Snoredog** » Thu Sep 28, 2006 1:33 pm

very simple. FAIL your cpap trial. How?

1. Start complaining about breathing against the pressure.
2. Tell your doctor you sleep on your side, on your back, on your stomach.
3. Complain of aerophagia (swallowing of air) and abdominal pain associated with it. If you have GERD it is made easier.

Of course your pressure needs to be greater than 10cm to justify that approach. Try the cpap machine for 1 week, tell the doctor you cannot use it any longer and you want to try a Remstar Autopap w/Cflex or look at surgery options.

Snoredog · Post by **Snoredog** » Thu Sep 28, 2006 1:39 pm

[quote="svh"]OK. I've just emailed the doctor saying that I am not eligible for APAP, according to my insurance, and I am OK with that. I really do want the capability to use the tracking software, so I asked for a Remstar Pro 2 C-Flex CPAP, since it appears that is the lowest model that has the smart card. We'll see what she says. I'm not trying to get more than I need, but I know I am the anal, geeky type that needs to look at real numbers to see how I am doing. I know I may well have to pay for the software myself, I just want to be sure I get a machine that is compatible.

svh · Post by **svh** » Thu Sep 28, 2006 1:43 pm

Thank you, that's good to know!

svh · Post by **svh** » Fri Sep 29, 2006 11:02 am

OK. So, the sleep doc faxed my script to Trusted Life Care, a DME. I called them; they were delightful. I will be getting a M-Series w/ smart card and heated humidifier. Yay. I'm fine with that. If I actually have trouble with it or feel the need for whatever reason, I'll try for an auto, but it just didn't seem worth the trouble at this point, given my low pressure and pretty basic needs. I didn't get the impression I would have to pay anything at all, but we'll see. I expect I'll have to order the card reader and software, right? It will come with the card.

Thank you all for your support. They're calling me back later today to set up a visit, and will bring the Hybrid and the Swift masks for me to try (my requests) Any other suggestions? I want to be able to read in bed with glasses, so don't want a lot of stuff over my face. I wasn't successful with the nasal mask I wore at the sleep study (Comfort Lite--I didn't like the style, and it leaked), but they didn't give me anything else there, so I still need to experiment.

Wulfman · Post by **Wulfman** » Fri Sep 29, 2006 11:16 am

svh,

Make sure they give you (at least) the M Series Pro.
There is also an M Series "Plus" model that has an optional smart card but doesn't record any meaningful data.

The only machines in the M Series CPAP/APAP categories that record sleep data are the Pro and the Auto.

Best wishes,

Den

svh · Post by **svh** » Fri Sep 29, 2006 11:28 am

Thank you--that's really helpful. I'll be sure to get the PRO. Thanks!

svh · Post by **svh** » Fri Sep 29, 2006 11:45 am

Just spoke with them and they are bringing a Remstar M-Series Pro w/ C-Flex and smart card, specifically the Hybrid and Swift masks to try (as well as others). If I choose the Hybrid, my grand total expense will be $8, since insurance covers nasal masks 100%, ff some lower %. I said I could live with that! I gather I am covered for $1500/year DME, so insurance will be buying the machine and mask, she said, not renting.

How does this sound?

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CPAPopedia Keywords Contained In This Post (Click For Definition): C-FLEX, swift, DME, Smart Card

Wulfman · Post by **Wulfman** » Fri Sep 29, 2006 11:52 am

Ya done good!

Best wishes for good sleep.

Den

svh · Post by **svh** » Fri Sep 29, 2006 12:13 pm

Thanks--they're not coming till Thursday....I guess that gives me time to get mentally prepared!