CPAPtalk.com

So my ins co and DME had a conversation. Next step is for ins co to talk w/ my doc (allergist, not sleep doc) to verify there is a medical reason for me to have an APAP -- and if there is, to get a pressure range rather than a straight pressure. Also will need to get medical reason for needing data capable.

My doc is not in on Tues so I called and asked for her to call me BEFORE she calls ins co. Because of the pressure range issue, my original Rx was changed from APAP to CPAP. THis is how it now reads:

C-Pap w/ heated humidifer and usage data capability. DX Sleep apnea/excessive daytime sleepiness. Set at 7cm pressure, mask of patients choice. For efficacy and usage data access

My original sleep study reports indicate that # of events: Prone NR: 2 Prone R 0; Supine NR 37 Supine R10; Left NR 6 left R0.
My titration interpretation reads "... CPAP settings of 4,5,6,7, cm were tested. ....7cm effectively treated the patient's OSA and was tested during REM-supine sleep. CPAP setting of 5 & 6 cm was almost as effective, but were not tested during REM sleep. Frequent periodic limb movements during sleep were noted."

My understanding of these two study results indicates the medical reason for APAP is:
1) apneas vary based upon position -- so auto adjust pap would provide a more precise pressure based upon needs;
2) The titration results are inconclusive as to whether pressure set at 5 or 6 would be as effective as being set at 7.

So what I need from my forum friends, is verification/suggestions/changes to why I need APAP. And also, medical reason for needing data capable machine. My wanting the info to track and follow my success was NOT a medical reason.

If I get medical reasons for these needs, insurance co will pay for it. Otherwise, I will incur an upcharge of $150 to get data capable.

Would love to know your thoughts and suggestions!

Lori

All APAP's are data capable so no reason to push on that. All you need to do is convince them on the APAP.

lanndi wrote:So my ins co and DME had a conversation. Next step is for ins co to talk w/ my doc (allergist, not sleep doc) to verify there is a medical reason for me to have an APAP -- and if there is, to get a pressure range rather than a straight pressure. Also will need to get medical reason for needing data capable.

My doc is not in on Tues so I called and asked for her to call me BEFORE she calls ins co. Because of the pressure range issue, my original Rx was changed from APAP to CPAP. THis is how it now reads:

C-Pap w/ heated humidifer and usage data capability. DX Sleep apnea/excessive daytime sleepiness. Set at 7cm pressure, mask of patients choice. For efficacy and usage data access

My original sleep study reports indicate that # of events: Prone NR: 2 Prone R 0; Supine NR 37 Supine R10; Left NR 6 left R0.
My titration interpretation reads "... CPAP settings of 4,5,6,7, cm were tested. ....7cm effectively treated the patient's OSA and was tested during REM-supine sleep. CPAP setting of 5 & 6 cm was almost as effective, but were not tested during REM sleep. Frequent periodic limb movements during sleep were noted."

My understanding of these two study results indicates the medical reason for APAP is:
1) apneas vary based upon position -- so auto adjust pap would provide a more precise pressure based upon needs;
2) The titration results are inconclusive as to whether pressure set at 5 or 6 would be as effective as being set at 7.

So what I need from my forum friends, is verification/suggestions/changes to why I need APAP. And also, medical reason for needing data capable machine. My wanting the info to track and follow my success was NOT a medical reason.

If I get medical reasons for these needs, insurance co will pay for it. Otherwise, I will incur an upcharge of $150 to get data capable.

Would love to know your thoughts and suggestions!

Lori

Was this information you just relayed coming from your insurance provider?

Some things to ponder:

At the pressure you're prescribed, you probably don't "NEED" an APAP.
A data-capable CPAP will do when used in conjunction with software. You don't have to have an APAP to get data-capability.


Your insurance provider is going to pay the EXACT same amount for whatever CPAP they get billed for.....cheapest through the most expensive APAP......they only have their profit margin at heart and not your therapy.
There is no justification for the DME to charge an extra amount for the machine you want.


Den

Wulfman

Was this information you just relayed coming from your insurance provider?

Yes, it was my ins provider who said I need to have MEDICAL reasons for needing APAP and/or data capable if they are to cover the expense.

At the pressure you're prescribed, you probably don't "NEED" an APAP.

-- I understand that APAPs are generally not "NEEDED" unless at a pressure of 15+ -- but do you think I would get better treatment based upon my theories:

My understanding of these two study results indicates the medical reason for APAP is:
1) apneas vary based upon position -- so auto adjust pap would provide a more precise pressure based upon needs;
2) The titration results are inconclusive as to whether pressure set at 5 or 6 would be as effective as being set at 7.

Thanks!

A prescription for an auto does NOT require a pressure range. When receiving a machine based on a prescription that simply says, "Auto CPAP", you should get a machine set wide open. On my Remstar tank it arrived ranged at 4cm to 20cm. A prescription that simply says, "Auto CPAP" is fillable as written.

yardbird wrote:A prescription for an auto does NOT require a pressure range. When receiving a machine based on a prescription that simply says, "Auto CPAP", you should get a machine set wide open. On my Remstar tank it arrived ranged at 4cm to 20cm. A prescription that simply says, "Auto CPAP" is fillable as written.

Unfortunately, not according to my Ins provider.

Justification for APAP??? You said it very well yourself:

"1) apneas vary based upon position -- so auto adjust pap would provide a more precise pressure based upon needs"

Reason for full data capability:

1] Data needed for indications of probable causes and solutions of therapy problems encountered to avoid costly in-lab re-titrations unless absolutely needed.

Ins. Co. policies vary widely. Perhaps a clue which Ins Co you are dealing with would be helpful.
Like Den said, the Ins. will pay the same whether CPAP or APAP. I would conclude then that this DME tainted this decision. With that in mind, unless you find another DME - you are in for more of the same.

I haven't seen any numbers but I would say (w/o ALL the info) - YOU will be much better off to buy from cpap.com

I still say, if you are going to deal with a local DME, you will be better off having a make/model specific script.

The data capable machine is needed to insure your treatment is effective.

To me, efficacy does NOT mean the data you will be interested in - leaks, apneas, hypops, snores, flow limitations, etc. I think this DME will take efficacy to mean hours of use.

Ins. Co. policies vary widely. Perhaps a clue which Ins Co you are dealing with would be helpful.

Blue Care Network - Michigan

I haven't seen any numbers but I would say (w/o ALL the info) - YOU will be much better off to buy from cpap.com

If I can get what I want, I'll be better off going thru insurance, but if not, I'll go w/ cpap.com.

To me, efficacy does NOT mean the data you will be interested in - leaks, apneas, hypops, snores, flow limitations, etc. I think this DME will take efficacy to mean hours of use.

I pulled that language from Our Wisdom on how to get script written. When I'm done with this process, I will submit some suggestions for better language.

Reason for full data capability:

1] Data needed for indications of probable causes and solutions of therapy problems encountered to avoid costly in-lab re-titrations unless absolutely needed.

Thanks, Slinky == that sounds good!

Gumby wrote:
Like Den said, the Ins. will pay the same whether CPAP or APAP. I would conclude then that this DME tainted this decision. With that in mind, unless you find another DME - you are in for more of the same.

I agree that somethings fishy . . . sounds to me like the DME influenced the insurance company. (No telling what the DME said!)

Since the Insurance Code is the same for CPAP's and APAP's, and insurance pays the same, it sure sounds strange that the insurance company wants proof of medical necessity for APAP beyond an Rx. I thought it was BiPAP's where you had to show medical necessity by the need for 15+ pressure. Could someone be confused? I'd call back the insurance company and stress that you are talking about AutoCPAP, ,NOT BIPAP, and that you understand that AutoCPAP doesn't require medical necessity by showing a 15+ pressure like BIPAP requires . . . & that you understand that the same Insurance Code is used for AutoPAP as for CPAP.

Then, I'd do what Slinky suggested and "interview" the new DME's by phone to be sure they do the following: 1) Participate with your Insurance Company, 2) carry the "specific" machine you want (tell them exactly) & that they WILL dispense that specific machine to you with the Rx you plan to use [make/model specific would be best]. 3) Affirm that they will NOT tack any additional charges on you for the machine you want).

Find out from your Insurance Company what you will be paying for a CPAP/APAP (noting the above that it should be the SAME for either), then compare that amount to the cost of purchasing it outright w/o insurance from cpap.com as Wulfman suggested.

I'd agree with Slinky's recommendations on the Auto CPAP machines:

AutoCPAPs [like "2 machines in 1", can use in CPAP or Auto Mode]:
** ResMed S8 Autoset II + integrated Heated Humidifier
** Respironics M-Series Auto CPAP with A-Flex + integrated Heated Humidifier

- or - CPAPs:
** ResMed S8 "Elite II" CPAP + integrated Heated Humidifier
** Respironics M-Series "Pro" CPAP with C-Flex + Integrated Heated Humidifier

This would be my "two cents". Sounds like you are getting some good advice here, and that you are on your way to "taking the bull by the horns"!

Good luck!

Joy

Try asking your insurance company, NOT about CPAP or APAP, but rather about HCPCS code e0601. You are NOT asking for or about an HCPCS code e0470 (bi-level). Maybe that will be a language they understand!!!! Duh.

I think (fingers crossed) the saga is over. However, my doctor is frustrated with the many calls and Rx she's had to do on my behalf for this -- and I think much of it is directed towards me.

However, right after I talked to my doc and BEFORE she called the insurance company, I talked to a VERY knowledgeable and helpful person at the DME. He is providing me with the IntelliPAP - AutoSet w/ data capability, but it will be set to CPAP not Auto. I'm not going to let that bother me! And he is sending out one of his most experienced RT guys to set me up! (Much better than the guy the originally sent who had NO CLUE what I was talking about!). He would have sent it today, but I'm going out for B-Day celebrations tonight and figured it was not the best night to start it. So I'll have it by noon tomorrow.

Thanks for the info and all the support. I will let you know when I officially join the Order of the Hoseheads!

Lori

Be sure to let us know how it goes. We love success stories.

lanndi wrote:I think (fingers crossed) the saga is over.

Is it over or entering another chapter?
Either way, good luck.

May you have the wind at your back.

Start reading about that machine, just so you know.

Good luck, Lanndi!!!