What happens after failed insurance trial period?

I'm with Horizon Blue, BCBSNJ. whenever you ask them about CPAP they tell me they follow Medicare guidelines.

First , I live in Texas. So when my bills are submitted and processed, they are submitted to BCBSTX (not BCBSNJ) who administratively processes them and is the point of contact if the DME has billing issues. If the Dr or I have pre-cert or coverage questions, we call BCBSNJ.

All I can din on this says you get a 90 day trial period, during which you must show at least 30 continuous days of compliance (4 hours per day?). What happens after this period if you are not in compliance? Do you need another titration study to verify correct pressures or are you screwed?

For reasons related to military service I am having a difficult time adjusting to wearing a mask at night. Its not something that has happened in 90 days, and now I am dealing with my insurance telling my DME I need another study before they will pay any more charges, but when my DR talks to them they say a new study, even just a titration study, is medically unnecessary. I am curious if any one has experienced this or knows the way it should work.

This is why many insurance companies require a machine rental and they don't buy them outright. Non-compliant and the machine goes back to the DME. Done. I don't have an idea of how or when it could be started up again.

Compliance and the determination of medical necessity are not set in stone. If you have a legitimate problem with compliance related to your military service, then talk with your doctor about it, and he might go to bat for you with insurance. I would use your regular primary physician, not a sleep doc. Sometimes a compliance failure results in the prescription of a different machine (bilevel) due to problems with patient tolerance. You have presumably been diagnosed recently with sleep apnea. A new study is not needed, but a legitimate reason for noncompliance needs to part of the doctor/patient discussion, with a plan for resolving the issue.

It is not a lost cause, but you will need to work with your doctor.

But, if you can afford to buy outright (see prices for Apap machines and masks - very wide variety - on Cpap.com), we can help you titrate your pressures and get set up. And if your MD won't write a script for a machine, you can find refurbished ones a lot less expensive on Secondwindcpap.com (we can help you choose an appropriate one). All you'd need is a copy of your sleep study results and if you have it, the prescription (copy) written for you. A lot of people do things this way when necessary.

I was told by my DME that to be compliant with my insurance I would need to use the machine 4 hours or more each night 70% of the time in a 30 day period. I have 11 days under my belt with an average of almost 8 hrs a night. Some nights I would love to just pull it off and snore away, but I am forcing myself to power though, trying different masks and hoping I get used to it. I actually like the forced air, it feels like it helps me breath. It has been either nasal mask movement and soreness of my nose with with nasal pillows giving me problems. I don't even mind the head gear or mask, as long as they are not causing me pain.

30 continuous days out of 90 seems weird, so you can go 60 days not using it, wear it for 30 and be good, as long as it's continuous? I may have to call my insurance to make sure what my compliance definitely is, I also have BCBS, but out of Illinois, and I live in MD.

Good luck.

bmusgrove wrote:I'm with Horizon Blue, BCBSNJ. whenever you ask them about CPAP they tell me they follow Medicare guidelines.

First , I live in Texas. So when my bills are submitted and processed, they are submitted to BCBSTX (not BCBSNJ) who administratively processes them and is the point of contact if the DME has billing issues. If the Dr or I have pre-cert or coverage questions, we call BCBSNJ.

All I can din on this says you get a 90 day trial period, during which you must show at least 30 continuous days of compliance (4 hours per day?). What happens after this period if you are not in compliance? Do you need another titration study to verify correct pressures or are you screwed?

For reasons related to military service I am having a difficult time adjusting to wearing a mask at night. Its not something that has happened in 90 days, and now I am dealing with my insurance telling my DME I need another study before they will pay any more charges, but when my DR talks to them they say a new study, even just a titration study, is medically unnecessary. I am curious if any one has experienced this or knows the way it should work.

Julie wrote:But, if you can afford to buy outright (see prices for Apap machines and masks - very wide variety - on Cpap.com), we can help you titrate your pressures and get set up. And if your MD won't write a script for a machine, you can find refurbished ones a lot less expensive on Secondwindcpap.com (we can help you choose an appropriate one). All you'd need is a copy of your sleep study results and if you have it, the prescription (copy) written for you. A lot of people do things this way when necessary.

I agree with Julie. It's probably going to be more expensive to get retested and all that, than to just buy the equipment out-of-pocket. Make sure you get a copy or original of your prescription and you can make this work. And, you won't be held to the standards of the insurance provider and DME. As she said, you can buy "new" from any number of sources like https://www.cpap.com or lightly used (and "like new") from places like http://www.secondwindcpap.com .


Den

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Horizon Blue, BCBSNJ. whenever you ask them about CPAP they tell me they follow Medicare guidelines.

First , I live in Texas. So when my bills are submitted and processed, they are submitted to BCBSTX

You need to contact your carrier and find out WHICH rules apply to you and exactly how they are interpreted. I say this because 30 continuous nights within a 90 day period is unrealistic. I haven't even managed 30 nights in a row compliance nights in a row. One in 7 nights, I get no sleep at all. 30 COMPLIANCE nights over a 90 day period is a completely different animal and certainly doable by you. Write an appeal and explain about your difficulties and also misunderstanding of what compliance actually means and whose rules apply.

Medicare is really plain with their explanation. Nightly compliance is AT LEAST 4 hours and you must have complied 70% of the time within the specified 90 day period.

bmusgrove wrote:I'm with Horizon Blue, BCBSNJ. whenever you ask them about CPAP they tell me they follow Medicare guidelines.

First , I live in Texas. So when my bills are submitted and processed, they are submitted to BCBSTX (not BCBSNJ) who administratively processes them and is the point of contact if the DME has billing issues. If the Dr or I have pre-cert or coverage questions, we call BCBSNJ.

All I can din on this says you get a 90 day trial period, during which you must show at least 30 continuous days of compliance (4 hours per day?). What happens after this period if you are not in compliance? Do you need another titration study to verify correct pressures or are you screwed?

For reasons related to military service I am having a difficult time adjusting to wearing a mask at night. Its not something that has happened in 90 days, and now I am dealing with my insurance telling my DME I need another study before they will pay any more charges, but when my DR talks to them they say a new study, even just a titration study, is medically unnecessary. I am curious if any one has experienced this or knows the way it should work.

Medicare Compliance
After the patient starts CPAP treatment at home there has to be documentation of patient compliance. This is done after 31 days but before 90 days of usage. They must have a download of the CPAP usage and a face to face re-evaluation with their physician. Their physician must document that the patients symptoms have improved. Adherence to CPAP is defined as usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of in

Julie wrote:But, if you can afford to buy outright (see prices for Apap machines and masks - very wide variety - on Cpap.com), we can help you titrate your pressures and get set up. And if your MD won't write a script for a machine, you can find refurbished ones a lot less expensive on Secondwindcpap.com (we can help you choose an appropriate one). All you'd need is a copy of your sleep study results and if you have it, the prescription (copy) written for you. A lot of people do things this way when necessary.

It sounds like you already have a prescription written, in which case it should be a part of your medical records which you are entitled to a copy of. A lot of offices don't want you to know this but it is the way it is; they can charge you a copy fee if they want to but most offices don't.

I can't help thinking that if a connection can be made between your military service
and your difficulty keeping the mask on, you are entitled to some slack.
Since this stuff tends to take more than the reasonable amount of time,
I suggest you get what you need on your own dime, and then consider getting justice later.

If BCBS is following the medicare guidelines, you must show 70% compliance during a thirty day period. Seventy percent compliance means you just use the cpap machine for 4 hours per night for 21 nights during a 30 day period. You have 120 days to meet this compliance requirement.

pwgphoto wrote:I was told by my DME that to be compliant with my insurance I would need to use the machine 4 hours or more each night 70% of the time in a 30 day period. I have 11 days under my belt with an average of almost 8 hrs a night. Some nights I would love to just pull it off and snore away, but I am forcing myself to power though, trying different masks and hoping I get used to it. I actually like the forced air, it feels like it helps me breath. It has been either nasal mask movement and soreness of my nose with with nasal pillows giving me problems. I don't even mind the head gear or mask, as long as they are not causing me pain.

30 continuous days out of 90 seems weird, so you can go 60 days not using it, wear it for 30 and be good, as long as it's continuous? I may have to call my insurance to make sure what my compliance definitely is, I also have BCBS, but out of Illinois, and I live in MD.

Good luck.

They don't have to be continuous days. They want to see a 4 hour average per night, for 70% of the nights. So in a 30 day period, they want to see you use the machine for 21 nights where you average 4 hours per night. They give you 90 days to meet this compliance.