Insurance bought machine without asking if I wanted it

Just received an Explanation of Benefits notice today from my insurance company (CDPHP), sent 7/12/11. Apparently they paid Apria for half the purchase of my CPAP machine on 5/23/11 (at 3 months), and I am now responsible for paying the other half ($379.00). When I asked the insurance company if anyone was going to ask me if I wanted to purchase the machine, they looked into it and said that prior approval should have been done, and if I don't want the machine I need to bring it back to Apria so the insurance company can recoup the money.

I'm confused: I thought I could rent the machine and then decide to buy after 13 months, not three!

I'm also not clear as to whether I want to purchase it. I have resolved the mask issues so I am able to use it during the normal 6.5 hours of sleep I get in a 24-hour period. But I still have the middle-of-the-night insomnia and am more tired using the machine than not using it. If the insurance company had asked me a week before my three-month mark if I wanted to buy the machine, I would have said no, because I had only just started being able to use the mask for 4 hours/day a few days before and still was not able to wear it all night, even when awake.

I saw my sleep dr today who confirmed that I have UARS, not apnea, and that I do not need to worry about future strokes or heart attacks if leaving the UARS untreated b/c I am female and don't have apnea. So the only reason I would want the machine is in hopes that if I stick with it long enough, it will reduce/eliminate the insomnia and/or improve the quality of sleep (my RDI was 45 at the sleep study) so that I feel "not-tired behind my eyes and with a cool, clear head," like I did that one time in my whole life. I saw the doctor before receiving the notice from my insurance company so I didn't get to ask her if she thought I should buy the machine or abandon CPAP therapy. I had been planning to give it one, last try for a month but it looks like I need to make a decision soon.

What would you all do if you were in this situation?

That sounds like standard operating procedure to me. My insurance company purchases after three months of rental, because that's cheaper for them than renting for over a year, as you suggest. The ASV was purchased outright after three months on that (tried CPAP and BiPAP for less than three months each before the ASV, but that three month mark on the ASV triggered a purchase).

My guess is that the insurance company figures that if you are still using it then you must want it; I don't know that any call the customer to ask about buying it outright.

Are you on Medicare and the insurance company is a supplement, or is this your primary insurer? If it's your primary insurer, the rules may differ from Medicare. Don't assume anything, and don't expect the DME to tell you the correct information about YOUR insurance.

Request a copy of the Evidence of Coverage from your insurance company--that's the contract between you and your insurance company--you've never seen it unless you ask, it's not something they send you as a matter of course (It still flummoxes me how you can have a contract with an insurance company when you have never even seen the contract!) When you request the EOC you'll get a booklet outlining exactly how things are covered under your policy. By law, the insurer must provide you with a copy of the EOC upon written request, and how long they have to provide it is set by state law and varies in every state. It's 10 days in California.

BTW, insurance companies' employees often give the info wrong too, so always check the written materials in your EOC. When it all comes down to it, they MUST follow whatever it says in that document. Sometimes what they say is NOT in the document, never trust anything verbal unless it's in your favor.

$379 is nothing compared to your health. If you can't afford $379 one time for something as important as CPAP, you can't afford to eat, or have a roof over your head, either.

The question is whether you should do CPAP or not, not whether you want to spend $379 on a machine. Do you want to try and treat your symptoms? Don't forget that UARS does have long term effects.

By the way, don't put too much faith in the UARS diagnosis. I think sometimes, that's a diagnosis arrived at by eliminating other causes, not by actually proving UARS.

Thanks, All.

Bons, that's good to know that that is standard operating procedure (even if it's slimy).

Janknitz, CDPHP is my only insurer, and since they are saying to send the machine back to Apria so CDPHP can recoup its money from Apria, it sounds like the verbal direction is working in my favor. I think I'll skip drawing their attention to the fine print they didn't tell me about.

archangle wrote:$379 is nothing compared to your health. The question is whether you should do CPAP or not, not whether you want to spend $379 on a machine. Do you want to try and treat your symptoms?

Yes, you are right about the question being about whether I want to do CPAP or not. I was able to rig up a mask situation that both fits and is functional, and feel reasonably sure that my air pressure level is correct. But even so, I feel horrible after a night on the machine. Hung over. Way over the top of my already over-the-top fatigue and sleepiness. Nevertheless, I kept up with it diligently for 3 weeks. When I asked my sleep dr yesterday about it, all she could come up with was "sleep inertia," which is supposed to wear off shortly after I get up for the day. She then speculated that CPAP downregulates my autonomic system, but then the high degree of mental activity that floods in within minutes of my waking up somehow wipes me out. I have no idea what she is talking about, and remain unpersuaded that CPAP therapy can work for me.

I was thinking of it this way: If I were an employer who hired the one person in the world who could do very important Task A, I would expect to have to introduce the new employee to her co-workers and provide her with some training. But if, after 3 months of constant helping her to get along with her co-workers (on whom she leaves a deep impression, rubs the wrong way, and makes uncomfortable) and removing every obstacle to her doing her job, she not only does not accomplish Task A, but actually hampers my company's effectiveness in the specific area for which she was hired, I might certainly be compelled to fire her—even though she came with a promising resume and great references.

OTOH, I was also thinking of it this way: I am longing to live the life I want to live without constantly having to modify activities and limit the degree to which I engage with the world in an effort to conserve my energy. I look at the author bios on the backs of their books and so frequently see that so-and-so has a PhD, wrote 3 books, started thus-and-such foundation, and has three children, and I hate the way I'm pissing away my life just trying to get through and recover from my work day.

I would like to think my new employee could enhance my life, but she has only done her job correctly once in her 90 days of employment. I'm thinking that I'd get a better return on investment with that zany Australian chick, Ms. Didgeridoo, who requires a slightly lower salary and is a lot more fun to be around.

I'm struggling with this decision.

archangle wrote:Don't forget that UARS does have long term effects.

I asked the sleep dr about this yesterday and told me that it doesn't, but you are so right. I see them already, after only 20 years of insomnia and probable UARS.

archangle wrote:By the way, don't put too much faith in the UARS diagnosis. I think sometimes, that's a diagnosis arrived at by eliminating other causes, not by actually proving UARS.

Interesting. The sleep dr never mentioned UARS to me; I learned about it here, felt strongly that that could be my case, and the dr confirmed it when I asked her about it directly. It makes so much sense, and I was actually relieved to discover what seems like an accurate label for it. I made this chart to help me get my head on straight about what I was reading:



The chart is still somewhat incomplete: I left some blanks on the Apnea side b/c I don't know whether those symptoms also apply to Apnea or not. But every point on the UARS list is my experience, except for the last item, "Symptoms more severe than in Apnea patients," which I have no way of knowing. I have only two of the items on the Sleep Apnea list: I feel sleepy, and I could be part of the 8% of female Apnea patients—though I'm more likely in the 50% of female UARS patients.

I'm not sure I agree with everything in the chart on the sleep apnea side. For example, I think there is a lot of insomnia, because of interrupted sleep cycles, frequent urination at night, and reflux. It may be that sleep problems don't show up until the SA is pretty advanced, however.

I think that the figure that only 8% of apnea sufferers are women must not be accurate any more. I think for a long time, only men were considred to fit the "profile" and women were not tested as often. My guess is that updated figures will be different.

I think that OSA suffers have a lot of skeletal pain issues and may have fibro diagnoses (remember, women are more likely to be diagnosed with fibromyalgia and they seem to be underrepresented in the population that gets tested for OSA).

I think there's a high degree of anxiety with OSA as well. With OSA we sleep all night bathed in stress hormones because of inability to breathe--the flight or fight system is engaged literally all night long. I had what was almost a full-blown panic disorder before starting CPAP (which made learning to sleep with CPAP much worse). It has changed dramatically since using CPAP--I'm not in constant battle stance anymore.

I called Apria. They explained that the money I had been paying each month has been contributing to the ultimate purchase in the fourth month. Insurance has been paying the other half, so I don't owe anyone anything and I own the machine. YAY!!! I'm so happy! I really was torn about whether I wanted to continue on with CPAP or stop. For the amount I've paid, yes, it is worth it to keep trying. I'm so used to horror stories about insurance in this country. Here's a case where my life has been graced by it, and I am very grateful. That is, if I really understand it correctly, now. This sort of thing is very confusing to me!

Anyway, you all are stuck with me for a while.

napstress wrote:Anyway, you all are stuck with me for a while.

Good!!!

Great news!

However, we should start a pool on whether Apria keeps billing you for the machine.

Janknitz wrote:I'm not sure I agree with everything in the chart on the sleep apnea side.

+1.

I haven't spent any time following UARS on this board or elsewhere, but as an SA sufferer I get cold hands and feet and indeed all over when I sleep, even though my thyroid function tests as normal. This was much worse without CPAP. Without CPAP I also had a strong preference for sleeping on my side and not my back.

My first impression looking at the table (and to repeat I haven't been following UARS) is that there isn't much of a distinction between UARS and OSA.

I'm glad you get to keep your machine.

archangle wrote:However, we should start a pool on whether Apria keeps billing you for the machine.

If they do, I'll have to hire some of those ninjas to go after 'em.

napstress wrote: When I asked my sleep dr yesterday about it, all she could come up with was "sleep inertia," which is supposed to wear off shortly after I get up for the day. She then speculated that CPAP downregulates my autonomic system, but then the high degree of mental activity that floods in within minutes of my waking up somehow wipes me out. I have no idea what she is talking about...

I have no idea what she's talking about either, and I suspect that if you asked her point blank to explain what she means, even she would have to admit that she doesn't have any idea what she herself is talking about.

OTOH, I was also thinking of it this way: I am longing to live the life I want to live without constantly having to modify activities and limit the degree to which I engage with the world in an effort to conserve my energy. I look at the author bios on the backs of their books and so frequently see that so-and-so has a PhD, wrote 3 books, started thus-and-such foundation, and has three children, and I hate the way I'm pissing away my life just trying to get through and recover from my work day.

Having three children is the easy part. It's doing that much laundry that is the true test of stamina. Children, even short ones whose clothes are very small, have this amazing ability to produce mountains and mountains of laundry... But I digress.

The chart is still somewhat incomplete: I left some blanks on the Apnea side b/c I don't know whether those symptoms also apply to Apnea or not. But every point on the UARS list is my experience, except for the last item, "Symptoms more severe than in Apnea patients," which I have no way of knowing. I have only two of the items on the Sleep Apnea list: I feel sleepy, and I could be part of the 8% of female Apnea patients—though I'm more likely in the 50% of female UARS patients.

The first three items on your chart are part of the definition (i.e., UARS is an AHI<5, etc.). The rest of the things on the list are either nothing I've ever heard of (e.g., I have never heard that insomnia is more common in UARS than it is in OSA) or are correlates (e.g., low blood pressure). I don't believe in the fatigued vs. sleepy distinction. For one, I've never heard that in UARS they are more fatigued than sleepy, and secondly, patients don't accurately distinguish the words "fatigued", "sleepy", and "tired" (e.g., My "sleepy" may be your "fatigued").

I think the distinction between UARS and OSA is in large part due to inconsistencies in scoring of hypopneas. If a lab requires desaturations for a "hypopnea", then that lab is more likely to call that type of event a RERA. A lab that allows for hypopneas with arousals and without desaturations is more likely to call it a hypopnea. I could be wrong, though.

Better than the question, "If I have UARS, do I HAVE to use CPAP?" is the question, "If I have respiratory events in the absence of desaturations, do I need to use CPAP?" Most of what we know about the health risks are, as far as we know, due to desaturations. However, "pissing away" ones life sounds like more than just a "risk", but a reality. Personally, I want the career, three books, etc. (NOT the 3 kids, though!), and pissing away my days until I hit the veil is pretty strong motivation for me.

Napstress-
Did you see that Dr Parks is having a teleseminar on uars next Tues? He is interviewing Dr G from Stanford. Look at Dr P's website to sign up.

Bright Choice wrote:Napstress-Did you see that Dr Parks is having a teleseminar on uars next Tues? He is interviewing Dr G from Stanford. Look at Dr P's website to sign up.

Oooooh! Thanks for letting me know about it, BC! I'm going!

SleepingUgly wrote:Having three children...

I don't at all want children either (or the PhD, for that matter); I just want the energy it takes to have them, and as you point out, raise them!

SleepingUgly wrote:patients don't accurately distinguish the words "fatigued", "sleepy", and "tired"

I believe they are using these words as Dr. Krakow distinguishes them: sleepy = you can't keep your eyes open, are nodding off; tired = your body is tired, as in after a day's work, but if you sat down in front of the TV or something you wouldn't drop off to sleep; fatigued = long-term tiredness.

SleepingUgly wrote:I think the distinction between UARS and OSA is in large part due to inconsistencies in scoring of hypopneas. If a lab requires desaturations for a "hypopnea", then that lab is more likely to call that type of event a RERA. A lab that allows for hypopneas with arousals and without desaturations is more likely to call it a hypopnea. I could be wrong, though.

Thanks for pointing this out. My dr is apparently in the former camp. I didn't know there was another camp.

SleepingUgly wrote:Better than the question, "If I have UARS, do I HAVE to use CPAP?" is the question, "If I have respiratory events in the absence of desaturations, do I need to use CPAP?" Most of what we know about the health risks are, as far as we know, due to desaturations. However, "pissing away" ones life sounds like more than just a "risk", but a reality. Personally, I want the career, three books, etc. (NOT the 3 kids, though!), and pissing away my days until I hit the veil is pretty strong motivation for me.

I like the way you reframe questions, SU.

I'm fatigued and sleepy for some reason, and have been ever since childhood. All my bloodwork has always turned out lovely. The only thing that's ever come up that is "abnormal" is my RDI of 45 events/hour during my sleep study—and the insomnia that drove me to see a sleep dr in the first place. So, now that I know that I have already paid for the machine in full, my answer to your very accurate question is "I am going to continue using the machine for a couple more months to see if it reduces/eliminates my insomnia, fatigue and/or sleepiness, regardless of whatever they might call my SDB."

You've mentioned before, SU, that you have UARS. What indicators made it clear to you that that's your diagnosis? Do you know of other resources specific to UARS?

Actually, I don't have UARS. I expected them to find UARS, but I was diagnosed with OSA. I had an RDI of 4 in NREM and an RDI of 58 in REM for an overall RDI of 15 (and continuous FLs in NREM that don't factor into those numbers). I said to the doctor, "So in NREM I have UARS and in REM I have OSA?" He said once they diagnose OSA, they don't diagnose UARS. At another lab, they might have called me UARS because my hypopneas were not associated with desaturations. As it was, at many labs, they called me nothing and missed the diagnosis altogether because even if I had an RDI of 10 in REM, they ignored that due to a nonsignificant overall RDI.

I have read Dr. Guilleminault and Dr. Avram Gold, and a few miscellaneous others re: UARS.