CPAPtalk.com

As someone who works for a health insurance company I can tell you this:

There is a single code for both CPAP and APAP - some companies do however have separate medical policies dealing with a CPAP versus an APAP. Most companies will publish these policies on their provider website (most in the non secure area so anyone can access - you just need to hunt and search). If they do have separate polcies, they may or not suspend the code for review of the type of machine. They may instead rely on network providers to do this for them (and do an audit on a post payment basis).

As far as a network provider making you pay extra for DME - most likely the answer is yes. DME providers are different than most health care providers in that they can provider 'deluxe' equipment when the standard equipment would meet the medical necessity guidelines. As a benefit to the customer (and believe or not most customers do consider it a benefit) - the DME provider can provide the deluxe item, and get paid for the standard, with the customer picking up the balance. This is actually consistent with how CMS processses DME claims (http://www.cms.gov/manuals/downloads/clm104c20.pdf). They may make you sign a ABN (Advanced Beneficiary Notice) regarding this matter.

As far as I know there is no state that *requires* a plan to follow CMS medical policies and reimbursement. Not even plan covered under federal ERISA laws (mostly large self funded accounts) are not required to do this. Most companies are required to use the standard codes sets due to part of HIPPA (I think it is part of HIPPA anyway - it is too cost prohibitive to develop your own codes when someone else does it for you anyway). Code E0601 covers both CPAP and APAP, but that doesn't mean your carrier has the same policy for both services. Whether or not they will pay the CPAP allowance when the service was actually a APAP may depend on the carrier.

Getting the doctor to write a specific prescription for a APAP is one way of forcing the provider to give you one, but that doesn't force your insurance carrier to actually cover it (or even allow the CPAP allowance).

I am glad to see Gia post. She saved me some of what I was going to write.

My insurance will cover a "basic" CPAP. There are hoops to go through to get them to allow me to get an APAP. This is part of the medical necessity statement needed. The insurance doctors (those guys who work for them not us) can review any of these requests for say an APAP or say for a BIPAP and say NOPE. Then the patient gets the CPAP no frills, no bells, no whistles model.

When I got my first machine (using insurance - others have been OOP) the RT knew my insurance paid well enough that if I had a script for an APAP that would have gotten me one. Each DME will know how rough each insurance they work with is on this. Some insurance companies don't even reimburse for a CPAP at the cost the DME has to pay for the APAP; some do. Each manufacturer has different prices so the new S9 Auto is pretty pricey still compared to other APAP's.

I have seen ppl here go in to the DME with a script for an APAP and walk out with a CPAP because the "medical necessity" isn't there. It doesn't happen very often but it has happened.

The OP was asked to provide the letter of medical necessity I believe (hence the DME's knew the insurance company well).

Thanks for that information Gia and Jules. My insurance considers APAP "experimental and investigational" and not covered; I'm still going to see what the DME says about getting me a ResMed S9 but if my insurance carrier tends to play hardball on that policy then I'm afraid I'll have to settle for a regular CPAP since I can't afford to do it without the insurance.

Thanks Gia, jules. I learned something too. I guess I shouldn't be surprised.
It wasn't too long ago that ASV was experimental investigational.
The S9 Elite should be covered, right?

Chimakwa wrote:Thanks for that information Gia and Jules. My insurance considers APAP "experimental and investigational" and not covered; I'm still going to see what the DME says about getting me a ResMed S9 but if my insurance carrier tends to play hardball on that policy then I'm afraid I'll have to settle for a regular CPAP since I can't afford to do it without the insurance.

If you have to "fight" for something......fight for data-capability......it's far more important than an APAP. You don't "need" an APAP to tell you what pressure to use (that can be determined or tweaked in CPAP mode) and many people have their sleep disrupted by the changing pressures in APAP mode. They're also more difficult for new users to get used to......they don't know how to adjust their masks for a range of pressures and end up with serious leakage problems as the pressures increase......which also disrupts sleep.


Den

As Den said DATA is crucial.

I didn't have a script for an APAP but I was able to get the Pro 2 tank without hassle when I started. Again the RT had enough of an idea on how much my insurance would pay so that I had my choice of CPAP's she had. Not everyone with a CPAP script would walk out with data in fact, I recall something said about ppl on public aid getting the bottom of the line model unless their doctor was one of the group in Seattle who really looked at the data.

I was able to use the Pro 2 to self titrate.

Oh I'm not backing down on the data. My sleep center is big on having the smartcards read but I'll make sure I get one that I can keep track of my own numbers. Even if I hadn't seen how important it was on this forum, I'd want it anyway, because I'm geeky that way.

they probably only care about compliance data so having a card isn't enough

you want to make sure you get a machine with "real" data - so make sure your machine is on that list RG has compiled

Pro for PR1 or Respironics, Elite for Resmed are minimum models you want

My wife did the sleep study last night. This morning the technician told her she she needs more pressure than the first sleep study, but does not need BiPAP. That means I will have to pay the DME $150 to upgrade her machine to get data, or $250 to get her APAP. My wife does not care which machine I get her, but I am inclined to spend the extra money for APAP. The DME only had one S9 APAP in stock, so they will have to order another for her.

I used their sleep study machine instead of mine and I guess they monitored me. Last night was a congested night for me. I used the Lansinoh cream on my nostrils, and it seemed like it sealed. This morning the technician told my wife my FX mask was leaking all night. (I can't wait to get my S9 so I can track that kind of stuff.) It was the same mask I am used to. It was supposed to be the same pressure I am used to. But this morning, my left nostril was sore. I have no idea why.

My first impression of having C-flex turned on was that it might have been a tiny bit easier to exhale. But I would not have noticed C-flex was on if she had not told me. My second impression was that the air was very cold, even after I found the button on the machine that turned on the heater. I keep my heater on 4, but their heater was not adjustable (at least on the machine in the room). Heated air definitely makes my throat feel better. I can't wait to get the heated hose for the S9.

Thanks for all your help, Rick

you might consider an S9 elite and an S9 AUTO - and swap as needed - it all depends on how important that extra $100 is - both have data

I have been very pleased with my PR System One Auto. My doc prescribed a CPAP device with C-Flex (or the ResMed equivalent which doesn't come to mind). I have BCBS of NC, and my DME gave me the Respironics device. At that time I didn't know what to ask for or what to look for (a mistake most of us made, I would imagine), but I got lucky I suppose and was given a very capable machine.

jules, that's what I was thinking, but I'm not sure she would think much of "swapping them as needed". But I will try to talk to her about it.

k - just in this economy $100 can be a big difference for many people and might be better spent on other things

I know you said she was fussy about "her" computer too - oh well, all of my husband's computers except one have been the "hand me downs" I gave him and soon he will get another one to "break" and for me to fix - he did get the new monitor with the last system I bought for me and he does get the new keyboards and mice and speakers when I get new systems usually but the CPU is the "hand me down" - he is used to that treatment - for years he got his brother's clothes growing up