Frustrated with Insurance Company - I need help !!!!

[quote="cchase"]Hi cpapjack-

I too am new to the cpap business and walked away today from a meeting with APRIA's Respitory Therapist (RT) without accepting the equipment offered when she presented me a basic REMstar Plus without humidifier. She explained that this is all my insurance would cover, but as you've probably learned from others by now, there is only one insurance code for a CPAP machine, so I expect APRIA is working their profit margin to the max by offering me the least expensive option available.

I have BlueCross of CA, and they have pretty clear policies regarding the treatment of OSA:

http://medpolicy.bluecrossca.com/policies/MED/OSA.html

APAP is only considered medically necessary by BlueCross if your sleep study indicated a pressure of at least 10 cm H2O and you cannot tolerate the pressure you are prescribed with CPAP. My guess is that most insurance companies are following this policy, so you and your Dr. would need to meet both criteria to get APAP.

Notice that the BlueCross policy will not pay for Respironic's c-flex machines; they are considered to be investigational and to have insufficient research to support their use over conventional xPAP machines.

The BlueCross OSA treatment policy doesn't say anything about the medical necessary conditions for a humidifier, but the APRIA RT explained that I needed to be on CPAP for 30 days without humidifier, file multiple complaints with my doctor during that time period (probably needs to be the first 30 days of use), and then apply for a humidifier. APRIA's own website and literature never mention the use of a humidifer to treat dry nose, mouth, etc. In fact, their literature that I saw today suggested that I'd get use to it after 4-weeks (hence my suspection that problems need to be documented during the first month of use to have a chance of obtaining one).

I'm going to consult with my Dr. tomorrow, but have pretty much decided to purchase equipment on my own. I am not now eligible for APAP, as my pressure setting from my sleep study was 8. From what I've read in the cpaptalk.com forum, APAP is considered more useful to deal with variations in sleep position, weight change, and diet, whereas varying the air pressure during exhalation (c-flex) is helpful with higher pressures. I'm not sure why BlueCross doesn't make APAP available to new users; I want it because I expect to need my pressure titrated as I begin treatment and have seen others in the forum talk about how their APAP pressures changed over time and during a single night as they moved sleeping positions.

I also want to be able to monitor my progress and need software to give me some information about how well I am doing, making sure the mask is working right, etc. Once again, there is no BlueCross policy that pertains to monitoring capabilities of the machine, so APRIA's statement to me that I have no insurance coverage is probably related to their profit margin on the machine again or the fact that all xPAP machines I've looked at that can use software are APAP machines.

I'm very interested in how things work out for you. I'd suggest talking to your insurance company and obtaining a copy of their OSA treatment policy. It may help you and your Dr. say the right things to meet medical necessity criteria.

Good Luck.

-Chris

I almost agree with snoredog.

Except.

I DID get an Auto (remstar with heated humidifier) from APria without taking something else and complaining. It can be done. Maybe not at every apria office but you can't say that it can't be done

I DO agree that if you can't get what you want you may want to take what you can get and sell it, depending on what your copay is. Keep the mask of course. Some people report having 100% coverage. If you are one of those and just can't get what you want by all means take the plus and sell it.

Only problem with snoredog's ideas is that for my insurance I have to submit the card so they can read it to ensure that I am using it. Not a phone call. So I can't leave it in the box new to sell, nor can I not use it during the compliance period. If your compliance period involves responding to a phone call then you can do what he says.

I would also be careful with selling it before it is paid for. If for some reason something goes wrong with the purchase and the DME needs you to return it, you don't want to get billed for the "Purchase price" which will knock your socks off.

But overall. I am with Snoredog in the "play the game" mentality. Do what you can to get what you want and if that fails, take what you can, and buy what you want and sell the extra. It is a stupid, stupid system and you have to treat it as such.

Anonymous wrote: But overall. I am with Snoredog in the "play the game" mentality. Do what you can to get what you want and if that fails, take what you can, and buy what you want and sell the extra. It is a stupid, stupid system and you have to treat it as such.

I too agree with Snoredog, but that brings me to another question. How do you convince the DME to give you a brand new machine, be it the one you want or not?

And Snoredog, whoever you are, no I don't think I'm the first one to ever attempt this. Maybe I wouldn't have posted this question because I know there are other people's experiences out there such as this, but the search function of this forum is absolute crap. And just what does the comment "from the looks of my avatar, you better explain it to me?" I agree with most of what you said, but what makes you the expert?

I just started with this and the dme gave me an old used one - i found out by looking at usage and was pretty upset - so went back to dme and said I won't use a used one , I understand I will be 'owning' this and want a new one
I got one and they gave me an apap the new s8 vantage cpap/apap with humidifier - I was pretty vocal in front of their other clients about getting screwed by them so maybe that was it
but problem is if you dismiss the dme, then if you need a new mask, real hard to try them on over the internet
(i posted a really long response but can't find it - sorry if this is a repeat)
good luck