Insurance will not cover my ASV

I guess we kind of look alike, don't we?

I recieved a letter from BCBS insurance yesterday. They say they will not pay for BIPAP because my original sleep study says I tolerate the CPAP well. They even have compliance data from DME saying I use it regularly.

I will be having a talk with my doctor today.......

I am now doing a trial on the VPAP Auto to show it does not fix my centrals. I hope this is the ignorant, stupid, uncaring insurance company not knowing what they are saying and they meant to send me a letter saying they would not cover the ASV yet......

(I've worked in the insurance industry before).

For what it's worth (nothing...) your claim was almost certainly rejected by a barely over minumum wage paid "Claims Specialist" punching yes/no answers into a computer program. Don't take it personally.

However, you're not lost...

At the bottom of that refusal letter will be boilerplate about appeals and reviews and the process to make them happen.

DO THAT.

However, before you do that, get your ducks in a row. Talk to your doctor, have him (more likely his nurse, but he'll sign it) write a note saying precisely why he believes a different machine is necessary.

*Then* follow the instructions on a claim appeal. *IF* you have access to either an ombudsman for your health plan, or if you have a Insurance Specialist in your company's HR department (assuming you get your BCBS through your work), get them involved. Part of their job is to cut through Red Tape.

If the machine really is medically necessary (as deemed by your physician), you will end up there eventually. You might have to jump through some hoops, but you *will* get there.

What ARE criteria for getting a bipap? Can a sleep study look good but the patient just be unable to use CPAP at therapeutic pressures due to aerophagia?

Well, in my case the magic words were "non-responsive on CPAP due to..." appearing in the report.

Basically, you have to make any legitimate (sounding) medical case that CPAP won't work for whatever reason.

Like aerophagia?

And has anyone heard of a doctor prescribing a trial of bilevel, and the DME lending/renting out a bilevel for a month or two without necessarily buying it?

(Sorry if I'm hijacking. I can start a new thread.)

The "Rent to own" model is apparently kinda common (especially if you use Lincare).

Basically, you are leasing the machine from them for a period of time (6 months or so), with the insurance company picking up (most of) the tab. Then you own it free and clear at the end.

I'm not sure why they do it that way, btu it's what I'm on as well.

AlanMacNeill wrote:The "Rent to own" model is apparently kinda common (especially if you use Lincare).

Basically, you are leasing the machine from them for a period of time (6 months or so), with the insurance company picking up (most of) the tab. Then you own it free and clear at the end.

I'm not sure why they do it that way, btu it's what I'm on as well.

Insurance companies do that because some patients can't/won't handle CPAP. Sometimes the patient does the CPAP and it doesn't work. Sometimes you have to try a different type of machine later. The insurance company doesn't want to buy a machine that might not get used.

SleepingUgly wrote:Like aerophagia?

And has anyone heard of a doctor prescribing a trial of bilevel, and the DME lending/renting out a bilevel for a month or two without necessarily buying it?

(Sorry if I'm hijacking. I can start a new thread.)

My doctor said he was going to try me at 16 CmH2o and that may give me aerophagia. If it did he would get me a bi-level machine. If that happens, I will ask for the auto version. The difference in list is 250.00 and 151.00 on our sponsor's site.

Good Luck!

Well, it's encouraging that someone's doctor feels bilevel helps aerophagia...

It took all day but just got word from DME:

1. They have approval for 30 day trial on BiPAP.
2. Set pressure 7-18 with 4 Pressure support.

Hope I sleep well tonight. I would love for my centrals to just go away......

OK, so how is it a 30-day trial as opposed to them just Rxing bilevel? I want to work on getting such a trial myself!

Dr. Wants to put me on ASV but this is one of the hoops. After 30 days I will have to do another sleep study.

Just talk with your doctor and ask about how to address central sleep apnea.....

The insurance company doesn't want to buy a machine that might not get used.

Especially when they're paying the DME $1800 for a device with a MSRP of $650.