Need advice please

Hello everyone my name is Scott as you have guessed I am new here and this is my delema. I was diagnosed with sever sleep apnea in May of this year. Today I was told by my insurance company that they will not cover a cpap/bipap machine. There reason was that it is a considered experimental. I then contacted the home care center (I think that's what you call it) to buy a machine myself. Well the machine the doctor prescribed cost over $7000.00! Bottom line is I can't afford that. 90% of the machines I have seen on line are under $1000.00. What would be so special about this 7000 dollar machine?? and do I really need it??
Thanks for reading, Scott

scott122262 wrote:Well the machine the doctor prescribed cost over $7000.00! Bottom line is I can't afford that. 90% of the machines I have seen on line are under $1000.00. What would be so special about this 7000 dollar machine?? and do I really need it??

Which machine did your doctor prescribe? Did you see the denial from your insurance company? Is it possible it was billed with the wrong code? It seems very silly that they would say xPAP treatment is experimental.

There was another post floating around here in the past 30 days about someone who's insurance policy would not pay for anything having to do with 'sleep' problems. I don't know if it's a new trend or not.

As for the machine, the basic CPAP's may be under $1000 but some of the more advanced ASV's can run thousands. Do you know what kind of machine it is?

What diagnosis did your doctor give you? I agree it's possible that something was mis-coded, as CPAP's are long established treatment for obstructive and central apenas, BiPaps and ASV for more complex apneas. Nothing experimental about it.

However, if your diagnosis is RERA or UARS, it MIGHT be considered experimental. But those don't usually go along with the designation of "severe apnea".

So the first thing to do is to get hold of your medical records and sleep lab report. You should also get a written copy of the insurance denial and appeal the decision.

In order to do this properly, you will need to request IN WRITING a copy of your "Evidence of Coverage" (EOC). The EOC is the actual contract between you and your insurer. You've probably never seen this EOC because they only send it out on request. States vary on how long an insurer has to send you an EOC when you make a formal written request. Once you receive that, you can look to see if there are any exclusions for sleep apnea therapy or equipment. If there are not, they have to pay.

ameriken wrote:There was another post floating around here in the past 30 days about someone who's insurance policy would not pay for anything having to do with 'sleep' problems. I don't know if it's a new trend or not.

As for the machine, the basic CPAP's may be under $1000 but some of the more advanced ASV's can run thousands. Do you know what kind of machine it is?

FYI: viewtopic.php?f=1&t=65601&st=0&sk=t&sd= ... =insurance

Thanks very much for the advice, I believe this site is going to be a very helpful. I can answer a couple of questions. I do not know what kind of machine the doctor prescribed. 1st thing Monday I will call him and get as much info as i can. I do have the insurance denial letter. Also it was not miscoded my doctor called the insurance co. and talked directly with a doctor that represents the insurance co.
Here is a list of things i need to do and get, If anyone would like to add anything PLEASE feel free to do so.
Call doctor and ask for the prescription and my sleep tests reports.
Call insurance co. to get the "Evidence of Coverage"

Welcome to the forum Scott. Keep us informed on the latest. There are people here who can give you good advise on dealing with insurance companies.

As Janknitz said above, ask for the EOC in writing, not via phone. You need a paper trail on that request. Some insurance companies have excellent online platforms in which you can maintain a internal messaging account. Mine does that and all my written requests have been submitted via that system, and they usually respond within 24 hours.