wording of medical necessity letter

If you can get the doctor to prescribe an auto pressure range, your old machine can't do it. That might handle the "medical necessity" bit.

Another argument would be that the newer machine can record data to allow the doctor to evaluate your need for apnea without another sleep study.

I'm really appreciative of all the help here! Actually, I'm a "her" and need to indicate that on my profile. I think robysue's post sums it up well, more clearly written than mine. I'm full of emotion and feeling overwhelmed. In response to some of the posts - BCBS is my primary/only insurance; the s9elite auto is specifically checked on the Rx; don't think that the provider is trying anything underhanded - my gut feeling. I'm sure that the conference call was legitimate. The lady from BCBS emailed me the Corporate Med. Policy (at my request) for durable med equip and I'm reading from that. I've had no trouble getting cpap supplies over the years from BCBSNC.

When I started this process several weeks ago, I called BCBS customer service twice to find out what the guidelines are and was told the machine has to be irrepairable OR that I need a feature that is on newer models than mine- (EPR, in my case).
I have had several conversations with BCBS customer service and they don't seem to see a problem since my machine is 5 years old and I get a letter from doctor. They do remind me though, that its not until the claim comes in and reviewed that a decision is made (my gamble). The red flag came up when my provider called BCBS. But the conference call didn't indicate any red flag. I'm planning to call provider to see what's going on. Thanks, everyone.
I'll let everyone know how it goes.

HPM wrote: the s9elite auto is specifically

Just be clear. S9 Elite is a manual CPAP.

S9 AutoSet is a great auto machine that does everything the Elite does and more.

S9 Escape Auto is a horrible machine that records a lot less data.

Never specify S9 Auto. Be sure to actually say "AutoSet."

HPM wrote:When I started this process several weeks ago, I called BCBS customer service twice to find out what the guidelines are and was told the machine has to be irrepairable OR that I need a feature that is on newer models than mine- (EPR, in my case).

My BCBS PPO insurance plan (a very large group plan) will NOT replace a CPAP even if it is over 5 years old UNLESS it is "irrepairable" as you stated.

However, they would NOT replace a CPAP just because I would want a "comfort" feature (the EPR in your case).

I have read the BCBS policy regarding DME (Durable Medical Equipment).
It very plainly states that "medical necessity" may not apply even if the Doctor, etc. states that it is a medical necessity. In other words, the Doctor, etc. can NOT override the BCBS policy on Durable Medical Equipment Re "comfort" features or other features that do not affect the effectiveness of the Durable Medical Equipment.

I will tell you though that my DME Supplier has been telling me ever since my almost 8 year old CPAP turned 5 years old that they would in effect lie to BCBS in the claim they file for a new CPAP & note that my machine was in fact no longer operating (even though it is running as good now as when I got it almost 8 years ago). But, they do NOT yet know that when I do replace my current CPAP in the near future, I will be demanding a ResMed S9 AutoSet & not the Respironics they push. So, I don't know if they will be as agressive when they find that out.

By the way, you can go to the BCBS website for your policy & view the actual BCBS Durable Medical Equipment policy (the entire policy in fact as relates to your specific plan). To access the correct one for "your" plan, you will need to enter some identifying information that is on your coverage card.

HPM wrote:The lady from BCBS emailed me the Corporate Med. Policy (at my request) for durable med equip and I'm reading from that.

In that case, I will hold my darts until the lite comes on.

Responding to Steven - I'm already signed up on the BCBS site but haven't tried to access the info you stated - until just now. It comes up as "system unavailable or error... close all windows and try again" which I did but no luck. I will try later or tommorrow. Its the "benefits booklet" link, right? I can't find my hard copy, which I usually recieve each year.