mask not covered

The mask I was prescribed by the sleep doctor was not on the approved list from Aetna. I need a F&P petite mask. The DME gave me a comfort gel. I ordered and self-paid for the petite mask and it works better for me (less leaks and I can somewhat sleep on my side or stomach more comfortably).
I think that Aetna should cover future replacement masks and it's less expensive anyway. Do I call Aetna and ask for an exception or do I try through the DME? Anyone else have to do this? Thanks for any help you can offer!

Cathy

DarkSideOfTheMoon wrote:The mask I was prescribed by the sleep doctor was not on the approved list from Aetna. I need a F&P petite mask. The DME gave me a comfort gel. I ordered and self-paid for the petite mask and it works better for me (less leaks and I can somewhat sleep on my side or stomach more comfortably).
I think that Aetna should cover future replacement masks and it's less expensive anyway. Do I call Aetna and ask for an exception or do I try through the DME? Anyone else have to do this? Thanks for any help you can offer!

Cathy

Did somebody tell you that (DME or Aetna) or did you actually see the "approved" list?
Masks are billed by insurance codes.......your insurance provider shouldn't give a hoot or even have an "approved list". The categories and codes are: full face masks (A7030), nasal masks (A7034) and oral interfaces (A7044).


Den

I saw the list. He said Aetna changes it frequently. My DME was actually very cool. He told me the most expensive items on the list so I could choose them if I wanted to. I don't think he really likes the company he works for and said they already lose money on Aetna anyway. They make up for it in Medicare costs being overexagerated. Figures, huh?!!

DarkSideOfTheMoon wrote:I saw the list. He said Aetna changes it frequently. My DME was actually very cool. He told me the most expensive items on the list so I could choose them if I wanted to. I don't think he really likes the company he works for and said they already lose money on Aetna anyway. They make up for it in Medicare costs being overexagerated. Figures, huh?!!

Have you talked directly to Aetna? Was it Aetna that showed/gave you the list?
Or......did the DME employee have a list of masks and SAID that what was approved?
Did the list have Aetna's name on it?


Den

WOW, what Aetna plan do you have? I have Smart Choice POS with them and have NEVER heard anything about an 'approved list'. I just pick a mask, tell them how much and they pay 90%.

I'm sorry, Cathy, but Aetna does not cover people with your face shape.

Absurd.

jdm2857 wrote:I'm sorry, Cathy, but Aetna does not cover people with your face shape.

Absurd.

Guess Aetna isn't Pink Floyd fans....

Worse....I have petite features on a huge face. That must be it!!!! Who could not like Pink Floyd? That would be absurd!!

I don't remember seeing Aetnas info on the sheet. It was an excel sheet. I'll call them. Duh...why didn't I think of that. Must be the sleep debt.......and the recession........and my dislike for spoiled hollywood socialites.

Cathy in a weird mood today

DarkSideOfTheMoon wrote:Worse....I have petite features on a huge face. That must be it!!!! Who could not like Pink Floyd? That would be absurd!!

I don't remember seeing Aetnas info on the sheet. It was an excel sheet. I'll call them. Duh...why didn't I think of that. Must be the sleep debt.......and the recession........and my dislike for spoiled hollywood socialites.

Cathy in a weird mood today

Cathy,

Your experience has been related (in various ways) before. Basically, it amounts to the fact that (in all probability) the DME employee is flat-out LYING to you.......for whatever reason.
As I said, the insurance providers don't care what mask you get as long as it's coded correctly by the DME supplier. It's the DMEs who don't want to go to the trouble to order a mask that they normally don't carry or that they can make more money pushing another one off on you.

Good luck.

Den

The RX from our Dr stated "mask of patient's choice".