BCBS won't pay for Bi-pap

My husband was diagnosed with sleep apnea and was put on a cpap machine in August, which BCBS of Alabama paid all but the deductible. The doctor instructed us to bring back the chip from the cpap machine in 6 weeks to make sure everything was ok. We did this and the doctor was not pleased with the result. The doctor recommended another sleep study on 11/4 which BCBS paid for using the bi-pap machine. My husbands episodes decreased from 120 per hour (from first test for cpap) to 10 episodes using the bi-pap machine. Now BCBS is stating the bi-pap is not medically necessary. The DME company is filing a medical review, but I am very nervous about this. The bi-pap machine is 2400.00, which we don't have.

Has anyone else had this problem? Will the medical review help show that the bi-pap machine is better than the cpap?

So scared.,....I want my husband to have what he needs to make him better. I don't want to lose him....
Any advice is appreciated.

angie

The $2,400 price is fictitious and a replacement machine can be available for a lot less.
Since BCBS has already paid for a CPAP machine, its not unusual for them to say "What's going on? How come you need a whole new machine in less that two months?". That's just the way it is.


Could you post your equipment list so we can see exactly what you do have?
It could help in your getting the equipment from a different source at a much lower price.
For example, if your machine is made by Philips-Respironics and already has a humidifier, then all that needs to be replaced is the blower part which is quite a bit less than the whole unit.
Do you have the software to be able to see the results on your own? That often helps.

Angie... give it a bit of time, insurance companies will try to find ANY way they can to deny a payment. Your hubbies doctor and medical team will win out in the end and he will get the machine that he needs. They will pay once it is proven he NEEDS the bipap to live a better life. It all comes down to dollars and cents, once they figure out its cheaper to pay for a bipap now than pay for all the medical issues that he will have without a machine down the road .

nanwilson wrote:Angie... give it a bit of time, insurance companies will try to find ANY way they can to deny a payment. Your hubbies doctor and medical team will win out in the end and he will get the machine that he needs. They will pay once it is proven he NEEDS the bipap to live a better life. It all comes down to dollars and cents, once they figure out its cheaper to pay for a bipap now than pay for all the medical issues that he will have without a machine down the road .

I agree and I just wanted to add that you can stay on top of your doctor & DME, making sure they provide the insurance company with the documentation, that being the reports from the CPAP (showing it's not doing it's job), the data from the bipap sleep study (showing it was working) and your doctor doing whatever paperwork necessary saying the bipap IS NECESSARY.

They will and if you keep yourself in the loop as much as possible, you'll feel better that it will be okay.

I have gone through a fight with Medicare to qualify for a Bi Level device (Bi Pap is the trade name for a PR Bi-Level machine, VPAP is the Resmed trademark name) in just the last ten days. Medicare has several possible terms that have to be on the form to get a Bi-Level device. The words I needed were, "patient must have failed CPAP." The proof in my case, was an over nite sleep study. Another possible option being the kind of info your doc might have gotten from the two months of using the machine.

In any case, this is one time that the greed of the DME should be helpful to you. You can keep calling the DME to find out the status of the request to the insurance company, unless you have a number inside the insurance company. Make sure your request/case does not get forgotten.

You might get some peace of mind by requesting the exact wording BCBS requires, and the wording already supplied by the doctors office.

Any bi machine has full data, not all of them have the "Auto" feature. You need to push to make sure the docs office writes a script for an auto machine, I think the prices are nearly the same for either an 'Auto' or one that does not have "Auto."

You can also go to our sponsors website, (and I do not work for them) to admire the different Bi-Levels machines that are offered.

For a used machine, http://www.secondwindcpap.com is known to be an ethical provider.

Beware of buying from someone you can verify is a reputable provider. Some come onto the forum every so often trying to sell, but are really into fraud. If buying from an unknown, then some here say to use PayPal to cover your back. There are two who routinely offer some machines for sale on the forum, and I would trust them. One or both of them might contact you by PM if they see this and have a used machine now. If someone does offer to sell you something, then you can come back here and mention their name, and we can verify if these guys are well known to us as being reputable sellers.

If you need something related to comfort, mask liners, strap covers, specialized mask cushions, then I would say to look at the website. http://www.padacheek.com

Keep all the rest of us up with what is happening, if BCBS gets a bug up their whatever, then maybe some one here can help you out by helping you to find a machine in one way or the other.

What was his score on CPAP?

I can't tell from your description ("first test for cpap") whether the 120 was before treatment or on CPAP: if I understand correctly, it was 120 before treatment. And the score of 10 was from Bi-pap, right?

What was his pressure setting?

At least for my insurer, the criteria for bi-level includes:

"CPAP (E0601) has been tried and proven ineffective, based on a therapeutic trial conducted in either a facility or a home setting" and they cite to this 2006 article by Kushida et al..

In particular, the relevant section states:

While the literature mainly supports CPAP therapy, BPAP is an optional therapy in some cases where high pressure is needed and the patient experiences difficulty exhaling against a fixed pressure or coexisting central hypoventilation is present. This recommendation is based on 2 Level I studies which yielded no evidence that BPAP improves efficacy or adherence in the management of OSA compared to CPAP.

He had 120 episodes during his first cpap test, with O2 level at 64%. He had 10 episodes on the bi-pap during the 2nd test.

Thanks so much for everyone's information, this has really calmed my fears and gave me alot of info. I checked with the DME office today and they have all the office notes, drs notes and tests results and have been mailed to medical review as of yesterday. I will keep you all posted on the outcome.

Please continue to give advice/info as you think of it. It is really helpful to me and greatly appreciated!!

With insurance companies and the gatekeepers working for Medicare and the Vet's administration,
"No" is often the first answer. It does not have to be the final answer, especially if it's the WRONG answer.
If you are right, just keep fighting.

angie35016 wrote:He had 120 episodes during his first cpap test, with O2 level at 64%. He had 10 episodes on the bi-pap during the 2nd test.

I take it that means he had a "split-night study", where they diagnose for the first half of the night without any therapy, and then try therapy the second half of the night? (The alternative is a first night of just diagnosis, followed by a second night with CPAP.)

If it was a split-night study, the question then remains: when did he have the episodes, before CPAP or during? Or were some before and some during?

Also, when you say "episodes", it sounds like you mean "total", not per-hour (which is what "AHI" is: events per hour). Do you know what his AHI score was (again both without CPAP and with)?

I'm asking all these questions, because if (for example) he had 110 episodes all before CPAP, and only 10 with CPAP, then you're going to have an uphill battle convincing BCBS that 10 episodes with bi-level is appreciably better.

Similarly, they tend to consider an AHI of 5 (per hour) or better to be "adequate" for OSA, which he might have reached on CPAP. Of course, if you husband is still suffering from sleep disturbances, your doctor should be able to make a good case that CPAP treatment has failed. It's just going to take someone to review the case, rather than the easy approval it would be if the numbers were high.

just like every DME may have their own policies..... not even BCBS policy is the same

it's always best to review what your personal BCBS coverage actually states.

In 2003, when I was first diagnosed, I was given a constant-pressure CPAP, but I wasn't adapting very well and talked to the doctor. He immediately prescribed a dual-level CPAP, just a couple of weeks after the other one, for which my BCBS paid with no hesitation, whatsoever. The times are different now, BCBS is very different now, but you should be able to fight for it. Good luck!
McSleepy

I have never had a problem with BC/BS but my doctor just ordered a Respironics 960 biflex ASV machine and they are dequiring more than ever before. Usually what is ordered is approved same day. I am over a week into this as they are rsquiring my doctor to talk to theirs before its approved. That happened yesterday. My biflex machine was approved in less than 15 minutes.

hueyville wrote:I have never had a problem with BC/BS but my doctor just ordered a Respironics 960 biflex ASV machine and they are dequiring more than ever before. Usually what is ordered is approved same day. I am over a week into this as they are requiring my doctor to talk to theirs before its approved. That happened yesterday. My biflex machine was approved in less than 15 minutes.

Not a huge surprise. It's a $3100 machine instead of $1400. They'll want some assurance that you're exhibiting complex apnea.

My delays were in trying to get the ASV titration study approved, but for similar reasons. They needed to see a failure of CPAP and bi-level first, and the doc's assistant had accidentally marked me as having failed therapy at home, when I'd never had a machine at home. Once the lab called my carrier & explained that it was actually in the titration study that I failed, he got approval for the test.

After the ASV titration, approval for the machine was instantaneous.

Have you had your ASV titration?

BCBS did the same thing to me except it was my first machine. The doctor prescribed it after the titration test. BCBS said that it was not medically necessary. Even though my AHI was 38.6. I had to get the DME to send in more documentation showing that it was medically necessary. Once they did that it was fine. Good Luck. My bipap has really helped me a lot. my AHI is now normally less than 2. Less than 1 a lot of nights.

BC/BS bougbt me Respironics cpap/biflex machine 2.5 years ago. No get my complex apnea properly under control. After 4 sleep studies past 3 months they paid straight up for Phillips Respironics 960 Bipap autoSV advanced. Did take an extra 2 weeks for them to talk to sleep doc but no problem after that. No stupid lease or other con to roll responsibility over on me wben year rolls over. They cut a check for machine, two Res Med air quattro masks, 6 sets of filters and heated hose. Made effort to get all done before year end and copays are met. In 27 years never had a test or proceedure denied. I signed up for thier top line PPO when in 20's and they have never let me down even wben tbey flew a specalist in from out of state to put my leg back together after a motorcycle wreck and my primary wanted a heavy hitter instead of a.local. Even picked.up his plane fare and his choice brand of titanium hardware. BC/BS has paid for every test or proceedure ordered. Its not tbe company as much as the plan you opt to pay for.