how to convince insurance to pay for APAP instead of CPAP

svh · Post by **svh** » Thu Sep 28, 2006 7:33 am

So, I would like to start treatment w/ APAP. (AHI 41.2, pressure 10) From what I've read, it just sounds better, more control, etc. My insurance (Blue Cross hmo) only covers APAP after a failed trial of CPAP. It seems silly to me to go through that when the APAP machine does everything the CPAP does plus more. I called the insurance co., and apparently if the doctor writes for prior authorization, stating that the machine is medically necessary, I can get it. My question is, what possible reasons would there be for the APAP being medically better for me, without having failed w/ CPAP. Are there any, or am I just being greedy?

Guest · Post by **Guest** » Thu Sep 28, 2006 7:47 am

It is a common problem - how to get the insurance company to cover the unit.
Basically, you have to prove the reason why you need a fancier model (apap). You need to show them medical justification that the regular unit (cpap) will not work for you.
Granted - with the limited information those of us on a random internet mesage board have - it is of course extremely difficult to really make any qualified judgement calls. However based on what you've posted so far I suspect it will be a serious uphill battle. I would also strongly question the benefit to the added cost of treatment that an apap would provide.
If you want to try, you will need a prescription for an apap that gives a pressure range from lowest to highest settings. You will also need what is called a Letter of Medical Necessity. This is a brief statement from your doctor describing why the cpap will not work for you. Often this will be due to dramatically changing pressure needs, inability to tolerate certain pressures, or someone who has tried a standard cpap and it has failed to treat the OSA.

svh · Post by **svh** » Thu Sep 28, 2006 7:55 am

Thanks--that's what I needed to know. I do appreciate it! I suspect I should give up on the APAP and focus my energies (limited as they are) elsewhere. Your information was helpful.

tmaiberger · Post by **tmaiberger** » Thu Sep 28, 2006 8:09 am

Don't give up yet, the billing codes for the CPAP and the APAP are the same. The DME may need a prescription for the APAP for their records, but it is billed to BCBS under the same code either way. I would talk to the DME and ask them if the Dr precribes the APAP can they fill it. If they say that they can not, you might try a different DME. Also, politely ask them if they say no, why, since it is the same billing code for either. I also mentioned to my DME that even if their profit on the machine is less, I would be coming back to them regularly for masks and replacement parts that they can run through my insurance and long term they would make a significant profit. Just a thought, it worked for me.

The other option is to purchase on your own from the internet, which is not really as expensive as you might think (at least for the next two days for resmed machines). Analyze how much your copay will be for a machine under your insurance, it may only be that you would pay a couple hundred more to purchase outright. In addition, the internet DME (like cpap.com) will sell you an APAP with a prescription for a CPAP.

SelfSeeker · Post by **SelfSeeker** » Thu Sep 28, 2006 8:12 am

svh,

The code for auto CPAP machine on line is the same as a CPAP. There is no code for an auto CPAP.

What if you get prices for a CPAP from a DME and get the price from CPAP.COM for an auto CPAP. The Auto will be less espensive, will they pay for it then. They may agree to it.

Do you have your prescription. If not get it and keep it on hand.

Will they remeburse the cost of a CPAP and you cover the difference if you bought an auto?

I got this from CPAP.Com about prescriptions. (Some online places will not sell you an auto if it is not prescribed by a Dr.)

CPAP

Contains one of the following words or phrases "CPAP" or "Continuous Positive Airway Pressure"
Contains your physicians contact information
Contains your physicians signature
Contains your specific pressure.

Example: 9 CM/H2O
Example: 9
Example 14 CM/H2O
Example 14

Back to Question Back to Top Ask A Question

--------------------------------------------------------------------------------

APAP

Contains one of the following words or phrases "APAP", "AutoPAP", "AutoSet", "Auto CPAP", "Auto Adjusting CPAP", "Self Adjusting CPAP", "CPAP" or "Continuous Positive Airway Pressure" or similar term.
Contains your physicians contact information
Contains your physicians signature
Contains your pressure range (Optional, Not Required)

Example: 4-20 CM/H20
Example: 4-20
Example: 6-18 CM/H2O
Example: 6-18

CPAP prescriptions are accepted for Auto Adjusting (APAP) Machines.

svh · Post by **svh** » Thu Sep 28, 2006 8:13 am

I don't think I have a DME--I'd be getting my equipment directly from the sleep doctor. She has already ordered me a Hybrid mask. There has been no mention of getting anything from an outside supplier. I have an appointment for next Friday for "Setup,"at which I expect to be given a machine to take home. How do I work within this scenario?

SelfSeeker · Post by **SelfSeeker** » Thu Sep 28, 2006 8:19 am

Why is the Dr telling you want machine to get?

Did you try different masks, laid down on the floor with a pillow to see how they feel?

Call your insurance, find out if they will only cover you from this Dr, or can you get your supplies anywhere you want?

Getting your masks from somewhere you can try them on is good in my mind, as for the machine it is cheaper on line. If you are paying a portion of the equipement, it is in your best intrest to shop around.

If this Dr sends everyone to one place for equipement, or will hand you the equipment without consutling you, this may be a conflict of intrest. Call the Dr and ask for your prescription? Do you even know what machine you will be given? What if you do not like the noise or something?

svh · Post by **svh** » Thu Sep 28, 2006 8:26 am

I got the impression that this doctor isn't used to people asking questions or having opinions. There was no trying on of masks, except at the titration study, where I tried two, both of which leaked a lot.

tmaiberger · Post by **tmaiberger** » Thu Sep 28, 2006 8:40 am

Don't be nervous about standing up to a doctor. Tell him/her what you want/ask a lot of questions. Bring a note book and take notes. Force the dr to explain things to you until you understand it. Definitely get a copy of the whole sleep study report (not just the summary), and a copy of the prescription for a CPAP machine. There are a lot of posts on here about justifications for an APAP.

It also seems odd that the Dr is also the DME. You can call the office and ask the recep/nurse/whoever answers who the DME supplier is. If they ask why, tell them you want to verify for yourself with BCBS that they are a preferred provider and need the name and address of the office in order to do this. Or, you can go to the BCBS website and print off the list of preferred providers and bring it in to the dr and tell him/her to pick one of these.

Why the hybrid? Does the sleep study indicate you were breathing through your mouth?

Linda3032 · Post by **Linda3032** » Thu Sep 28, 2006 8:52 am

SVH, here is a link regarding trying to get an Auto and how to try to convince your doctor it is needed. I know you are tired and it doesn't seem worth the fuss, but why drive a Chevy when you can get a Caddy?

Just don't let the doctor pawn off an inferior machine when it will cost your insurance the same amount of money regardless of what you get.

viewtopic.php?p=98351&highlight=apap+doctor#98351

svh · Post by **svh** » Thu Sep 28, 2006 8:59 am

I just got off the phone w/ my insurance company. I asked if there is a local DME I could use instead of getting the equipment directly from the doctor. They said no. They said I could use APRIA, some sort of national company. Do you know anything about htis? Would they bring masks to try on? This is all such a pain. Here I thought my biggest hurdle was coming to grips with wearing a machine to sleep. I had no idea it would be such a pain to actually get the stuff! Grrr....

Wulfman · Post by **Wulfman** » Thu Sep 28, 2006 9:12 am

svh,

Several things you need to consider here:

The doctor works for YOU! You and your insurance are paying him/her.
(actually, your insurance provider works for you, too....I assume you're paying them premiums every month)
You need to have your prescription! It's good forever.
You have the right to a copy of your PSG report (from your sleep study).
You have the right to ask all the questions you want.
You have the right to get the specific type of equipment you want. (refer to line 1)
You have the right to purchase your equipment from whomever you like.

Ask your insurance provider if it would be possible for you to purchase your equipment out-of-pocket and have them reimburse you (if that is financially feasible for you)

Check with:

http://www.billmyinsurance.com/

and see if your insurance provider is listed there, and/or inquire with them if they can check to see whether your insurance provider will work with them.

Don't let these people (any of them) push you around. This is going to be YOUR therapy.

Best wishes,

Den

Guest · Post by **Guest** » Thu Sep 28, 2006 9:19 am

svh wrote:This is all such a pain. Here I thought my biggest hurdle was coming to grips with wearing a machine to sleep. I had no idea it would be such a pain to actually get the stuff! Grrr....

It really doesn't have to be. Sometimes I think we make this 100 times more complicated for ourselves than it needs to be.
From your previous post it sounds like your doc is certainly willing to really go out of the way to help you out. He/she ordered you the cpap when you asked for it and even got you the hybrid when you asked for it.
Aside from that, again I honestly don't see the reason to go the route of an apap for your particular situation. If you really want to go to all the trouble to try and get one, follow the process everyone has set out. Don't be partiuclarly upset though if your insurance company denies it as not medically neccessary.
I genuinely believe (again from the extremely limited information available to random strangers on the internet. Heh.) that all you need is a normal cpap.
People love to complain about how expensive insurance costs are, yet none of us ever wants to take responsibility for doing something about it. Someone else suggested to you 'Why drive a chevy when you can have a cadillac?'. How about because it's more expensive and won't provide much - if any - benefit over the chevy?
Also - due to the extremely low airflow rate needed to keep an airway open in your case (<5cm = AHI of 3) even a slight weight loss for you may completely alleviate your symptoms. So the whole process may be moot in 6 months if you are able to lose 10 pounds. Sure no one knows for sure but to me it sure is worth the effort to be able to completely avoid all this!
But hey, this is all just a non-medical opinion of some random person on the internet who only has a tiny portion of the information required to make a valid suggestion for you so take it for what you will!

svh · Post by **svh** » Thu Sep 28, 2006 9:41 am

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.

Guest · Post by **Guest** » Thu Sep 28, 2006 10:01 am

The Remstar Pro2 is a great machine and the same one I use. It's whisper-quiet and super easy to use. It has the smart card and anytime I want I go to the DME and drop off my card and pickup a blank one. They give me a copy of the results right then and there. It's full of lots of cool charts and graphs and everything.