DME won't submit to insurance for approval

RandyJ wrote:Some of the depression and anxiety meds have implications for sleep quality, particularly affecting the deeper stages of sleep. You may want to search this forum and google using the medication names and terms such as sleep quality or REM sleep and see what comes out...

I actually switched from being on Prozac for a year plus to Effexor earlier this year. I see that is one mentioned that can effect the deeper stages of sleep negatively now. I'm only on 75mg and was considering upping the dose as my mood has not been as in check lately. I'm also on .25 mg of xanax 3x daily and .50 mg at night. I also take 300mg Neurontin 4x daily but usually only remember to take it 3x. I've recently added some 5-htp to the mix at night as it worked for sleep in the past for me but so far not helping much lately.

My doctor is convinced I would benefit from APAP and feels the original sleep study in lab years back didn't accurately detect possible apnea episodes because I didn't fall asleep for enough hours then. The recent in-home study he also feels that the 1st two nights I didn't stay asleep long enough and mentioned that the 3rd night showed more in line with having episodes.

lazer wrote:45yr old male. Diagnosed with "mild sleep apnea" and heavy snoring. Also have been struggling with depression, anxiety, and never feeling rested during the morning or day. Waking up throughout the nights. Had an in home sleep study done beginning of this year through NovaSom per my family physician. He is supportive in me getting an APAP and feels getting me a better quality of sleep could likely fix much of my problems, however, we have hit a road block with the local DME. They won't even submit a claim to my insurance because they say that my "score" doesn't meet the criteria required. My doctor even wrote for per-authorization to my insurance back in February and the insurance finally replied March 27th with a per-authorization for 1 month rental but the DME still wouldn't go anywhere with this and continued to refuse me. I have been back in touch with my Doctor and Insurance and have supposedly got the insurance company to re-authorize the service for the end of this month through end of May. My doctor tells me once he gets this authorization he will talk the DME into at least submitting it. I have also contacted NovaSom and authorized them to fax me my sleep study which I now have.

Questions: What numbers am I looking for on it to even get an idea from you folks if I have any chance of getting the insurance to actually kick in on this? And I'm assuming if the DME does go with this 1 month rental this time, is that going to be enough time to produce any results or data to send back to the insurance for a permanent solution? I'm paid into my deductible so I am really pushing for this to be covered but if it isn't, I've priced out a somewhat affordable solution here at CPAP.com being the IntelliPAP AutoAdjust Travel CPAP, Heated Humidifier, and ADAM Circuit Nasal Pillow CPAP mask at around $620 shipped. Any advice on that selection?

Thanks, Ron

Have your doctor submit your medical records regarding your symptoms and the results of your sleep study to the insurance company and ask them if there is another DME you can use. DME's do know the "rules" but why they would refuse to provider the equipment is baffling. The 30 days is to verify compliance with the machine and verify the effects. You might also appeal to your insurance company on your own but it seems that they're not the problem. Do you mind sharing your results.

motherall wrote:Have your doctor submit your medical records regarding your symptoms and the results of your sleep study to the insurance company and ask them if there is another DME you can use. DME's do know the "rules" but why they would refuse to provider the equipment is baffling. The 30 days is to verify compliance with the machine and verify the effects. You might also appeal to your insurance company on your own but it seems that they're not the problem. Do you mind sharing your results.

Hi, I posted my recent results here: viewtopic.php?f=1&t=76948&st=0&sk=t&sd=a#p701848

While I realize this may or may not be the answer for me as a few posters also pointed out, the fact that my doc has been still pushing for it along with just not ever feeling well rested, ect... has me still trying to do whatever it takes to try out CPAP/APAP.

Julie wrote:viewtopic.php?f=1&t=70205&p=656899&hili ... al#p656899

That's the story of someone who systematically went through the process from study to Apap and back - it's not for everyone, but probably for a lot more than they realize, and you sound like you just might fit in the picture... take your time with it because it's worth it.

Julie? Was that the right link? It seems to be all about positional therapy and I couldn't find the story about someone going through the process from Apap and back...

Sounds like the DME isn't explaining things very well and not being patient enough to really go through exactly what is going on.

Now, let me preface this by saying I've been out of the DME business for a number of years now so some of this can easily no longer apply. Trust me when I say Insurance is very much a moving target and the rules can and often do change on a daily basis. However from what you've described I already felt I knew what was going on and your second post confirms that.

As someone else previously pointed out - Medicare Guidelines state that a patients AHI has to be above 5 to qualify for a CPAP. Below that amount, you can have a list of 100 separate doctors signing off on a prescription and your Insurance Company will still deny payment. Period. 100%. Not that they'll only pay a little amount - they will flat out deny the claim. It generally doesn't matter why the doctor says you need it - if it does not fit the pre-determined guidelines it's not going to be paid.

Now - the Insurance Company has spelled all this out ahead of time to the providers so they know this going into it. That's part of the job of a DME - knowing all the different insurance companies and what their individual requirements are for coverage.

Further, in many cases if a DME company puts equipment out on a patient and should have known ahead of time that the claim would be denied they are legally prevented from trying to collect payment from a patient. This was a regulation that came out of the early 90's when some scam artist medical providers would perform unnecessary treatments on patients even though they knew insurance would not cover it and then bill the patients huge amounts that they couldn't pay. Note that this is not always the case but often it is.

So if your AHI is less than 5, which it sounds like it is, your options would be the following:

1) Talk to a DME company about what, if any options your insurance company has for obtaining coverage for an item you don't meet the standard coverage criteria for. Usually something like a Medical Review Board or other term. This will involve a lot of work between you, your doctor and the DME. Basically, the Insurance Company may have extended criteria or something along those lines (IE - Medicare USED to require an AHI of 15. However, if it was 5-15 with an additional overnight sat report showing O2 sats of less than 89 for a minimum 30 minute continuous period AND the patient also had additional disagnoses of certain heart conditions than the claim could be submitted for review for possible coverage). Or you may just need a large amount of extra documentation from your doctor about *why* you need CPAP, what specifically would be treated, how it has been demonstrated to have helped you already, etc etc. In other words, prove to the Insurance Company that this can help you, not that your Doctor thinks it will help you. Insurance Companies do not pay for possibilities - they pay for things that have been proven to work. Keep that mindset when putting this paperwork together.

Bottom Line - it sounds like this DME could be more helpful. However, from what little we can tell it sounds like they aren't just deciding not to provide you something - they are doing what they have been told they can do by your Insurance Company.

Hope that clears things up - and probably makes them more cloudy at the same time!

mattman

lazer wrote: I actually switched from being on Prozac for a year plus to Effexor earlier this year. I see that is one mentioned that can effect the deeper stages of sleep negatively now. I'm only on 75mg and was considering upping the dose as my mood has not been as in check lately. I'm also on .25 mg of xanax 3x daily and .50 mg at night. I also take 300mg Neurontin 4x daily but usually only remember to take it 3x. I've recently added some 5-htp to the mix at night as it worked for sleep in the past for me but so far not helping much lately.

Some people don't need mood-altering meds of any kind when they get their sleep under control. This cocktail may prevent you spending enough time in deep sleep/REM. If weaning yourself off everything and seeing if you can sleep better is an option, you may want to consider it. Of course, that is a discussion to have with your doctor. Many doctors are pill pushers, and our culture convinces us that we "need" lots of pills to function normally. ("If I'm depressed, there must be a pill for that.") Cocktails are notorious for causing the very problem they are supposed to alleviate, so be aware...

I took an SSRI briefly several years ago; I personally don't believe that those drugs are designed to be used forever. But that is a personal evaluation and everyone is different. If you think that greater time in deep sleep and REM would be a benefit, it is something to consider.

APAP may have its advantages but I'm not sure how effective it is at addressing apneas caused by states of drug-induced muscle and CNS relaxation (maybe other forum members will address this point.) Of course there are machines that go above 20cm, so there is always that option. And while the APAP will address apneas, it might not be able to do anything about the REM sleep issue if caused by medications.

Good luck whatever you decide.

mattman wrote: Bottom Line - it sounds like this DME could be more helpful. However, from what little we can tell it sounds like they aren't just deciding not to provide you something - they are doing what they have been told they can do by your Insurance Company.

Hope that clears things up - and probably makes them more cloudy at the same time!

mattman

That is my whole problem with them. The lady was abrupt and closed the door on me initially back when the sleep study results were sent... Fine, so since my doctor had already told me he would support an appeal to my insurance if needed, I called the insurance but there was nothing to appeal since the DME would not even submit. I called them back to request they at the very least submit something to the insurance and she closed the door on me abruptly once again saying it's my score and they will deny it. So I'm asking myself, how in the hell do I appeal something which the insurance has nothing sent to them to appeal. So I call the insurance back and explain what's going on with them and they tell me, another route I can go is to ask my doctor to send some documentation in to support my need for a CPAP/APAP device and that they would review it which could take (4-6 weeks) and send a determination for pre-authorization which they did. So after all this work, back to the DME with another abrupt - my supervisor is out of town, this pre-auth does not guarantee payment, your score is not a 5 - I'm not doing anything with this till my supervisor gets back. So I wait the week, call back in and another abrupt answer from the DME stating the same thing all over again, her supervisor supports the denial, and the date the pre-auth for a month rental is expired.

That's how I was handled and that is what I have a problem with. It just seems odd that the insurance would be the one on my side in this while the DME is against me. I don't even expect them to just hand me the equipment, all I'm asking is they submit the damn thing to insurance... Fine if they somehow decide to deny it, then I at least have some closure to this and I can either decide to appeal or know I did everything I could and just buy the damn thing retail online. I'm not upset if I don't qualify for one, I'm upset with all the work I've put into this and the insurance opening the door with the pre-auth but the DME standing in the way.

RandyJ wrote:

lazer wrote: I actually switched from being on Prozac for a year plus to Effexor earlier this year. I see that is one mentioned that can effect the deeper stages of sleep negatively now. I'm only on 75mg and was considering upping the dose as my mood has not been as in check lately. I'm also on .25 mg of xanax 3x daily and .50 mg at night. I also take 300mg Neurontin 4x daily but usually only remember to take it 3x. I've recently added some 5-htp to the mix at night as it worked for sleep in the past for me but so far not helping much lately.

Some people don't need mood-altering meds of any kind when they get their sleep under control. This cocktail may prevent you spending enough time in deep sleep/REM. If weaning yourself off everything and seeing if you can sleep better is an option, you may want to consider it. Of course, that is a discussion to have with your doctor. Many doctors are pill pushers, and our culture convinces us that we "need" lots of pills to function normally. ("If I'm depressed, there must be a pill for that.") Cocktails are notorious for causing the very problem they are supposed to alleviate, so be aware...

I took an SSRI briefly several years ago; I personally don't believe that those drugs are designed to be used forever. But that is a personal evaluation and everyone is different. If you think that greater time in deep sleep and REM would be a benefit, it is something to consider.

APAP may have its advantages but I'm not sure how effective it is at addressing apneas caused by states of drug-induced muscle and CNS relaxation (maybe other forum members will address this point.) Of course there are machines that go above 20cm, so there is always that option. And while the APAP will address apneas, it might not be able to do anything about the REM sleep issue if caused by medications.

Good luck whatever you decide.

I know and understand what your saying. Ideally I would like to be off these meds. I did try for a 3 month period at the end of last year. My mood was ok until the holidays then things went sour and my psychiatrist got me going again on the meds. Sleep quality never improved while off the meds though. This has been an ongoing issue with me for as far back as I can remember. I do sleep but at times wake up frequently during the night. NEVER feel rested in the morning and don't want to get out of bed if I don't have to. And I can definitely tell that when my sleep is at the poorest, I am very irritable and just feel plain crappy the following day.

Just an update. I am still actively working with my doctor and insurance on this and have requested a newly dated pre-auth from insurance and have asked the Dr to send to another DME provider. I have also received a prescription authorization from my Dr to Cpap.com on file now so can proceed with my order if this new DME doesn't give me a shot at this.

Thanks again for all the posts and recommendations and special thanks again to Pugsy!

While as disturbed at the DME's refusal to even submit to insurance after a pre-auth as I am, I do have some feeling of resolve and satisfaction that I have stuck with this and done everything I can to get somewhere with this.

I have filed a case with the BBB regarding the DME and am considering filing a complaint with the Attorney General of Pennsylvania regarding their refusal to submit to insurance after a per-authorization was given. It is not right that the DME is the roadblock to medical care when my doctor and insurance are both in my corner and have given their approval.

SREKANT9 wrote:Go find a different DME. These days even Walgreens will handle the equipment. Sounds like this is a DME that also does sleep studies and wants you to come in for one of their sleep studies. You have your Dr and insurance approval, go get the equipment some place else.

Already been done New DME has issued me loaner equipment I am using at the moment and they are working with me through the next 2 months until my doctor orders another sleep study of some sort. I don't really know the specifics yet on what type of sleep study he has in mind.

I've been updating my progress in another thread.

SREKANT9 is a spammer. Replied to your post only so he/she could sneak his link to the insurance company in his signature.
I took care of the spam
They think we don't notice stuff like that but we do.

Pugsy wrote:SREKANT9 is a spammer. Replied to your post only so he/she could sneak his link to the insurance company in his signature.
I took care of the spam
They think we don't notice stuff like that but we do.

Grrrrr And here I thought someone stumbled onto my thread and revived it, lol

Guess I should have read the 'reply' title which I do see now.