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APAP Denied by insurance co
#1
Hi Everyone,
I have recently been diagnosed with OSA.
After 2 weeks of waiting for the authorization, I just got a letter from my insurance co.
They are denying authorization for the auto pap that my sleep Dr. prescribed (I talked him into it).
The letter stated that I have to fail on a regular CPAP machine before they will authorize an auto pap.
This seems funny, because they pay by the code and both the CPAP and APAP use the same code.

Has anyone else ran into this?
Any advise would be appreciated.
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#2
(07-15-2012, 04:30 PM)Winkler3 Wrote: Hi Everyone,
I have recently been diagnosed with OSA.
After 2 weeks of waiting for the authorization, I just got a letter from my insurance co.
They are denying authorization for the auto pap that my sleep Dr. prescribed (I talked him into it).
The letter stated that I have to fail on a regular CPAP machine before they will authorize an auto pap.
This seems funny, because they pay by the code and both the CPAP and APAP use the same code.

Has anyone else ran into this?
Any advise would be appreciated.
Welcome aboard - I think some insurance require the patient to fail CPAP in order to qualify for APAP. The doc can recommend APAP but in this case have show a proof that your apnea is not treated with fixed pressure and you need to be on a variable pressure to treat your apnea in different sleeping positions but don,t forget that they heard all the excuses before. Make sure you get data capable machine that shows efficacy data (AHI and leak) on the screen such as S9 Elite. Avoid ResMed machine with Escape in the name (S9 Escape and Escape Auto) and Phillips Respironcis machine with Plus in the name (PRS1 Plus). Its important to find a mask that fits you properly and is comfortable to wear...The mask is the key to successful therapy. Find out your supply replacement schedule so you can replace mask cushions, hoses, filters, etc ..
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#3
Hi Winkler3, First of all, Welcome! to the forum.! Have you taken a look at the following thread on this forum, the link is: http://www.apneaboard.com/forums/Thread-...octors-DME . Maybe this will help you. Insurance companies will try to wiggle out of as much as they can. Best of luck, I know how frustrating this can be.
trish6hundred
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#4
Hi Winkler3, welcome to the forum. I have an HMO for my insurance, and I doubt if there is any company out there that is more unreasonable than an HMO! I made the decision to do it myself! I went to Supplier #2 (Secondwind) http://www.apneaboard.com/forums/Thread-...plier-List and just paid for it myself! I got a gently used APAP machine for WAY less than what it is worth. Sometimes you just have to bite the bullet and treat yourself! But, at the same time, I do encourage you to go through the motions and do what the insurance company wants. Who knows? Maybe you will be one of those guys who do just fine on a CPAP.
Good luck!
As always, YMMV! You do not have to agree or disagree, I am not a professional so my mental meanderings are simply recollections of things from my own life.

PRS1 - Auto - A-Flex x2 - 12.50 - 20 - Humid x2 - Swift FX
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#5
(07-15-2012, 04:30 PM)Winkler3 Wrote: Hi Everyone,
I have recently been diagnosed with OSA.
After 2 weeks of waiting for the authorization, I just got a letter from my insurance co.
They are denying authorization for the auto pap that my sleep Dr. prescribed (I talked him into it).
The letter stated that I have to fail on a regular CPAP machine before they will authorize an auto pap.
This seems funny, because they pay by the code and both the CPAP and APAP use the same code.
Has anyone else ran into this?
Any advise would be appreciated.

Usually there is an appeals process.

I've also occasionally found the following line helpful: "You seem really nice and I'd hate to have to make the company have to take the time to respond to my attorney sister." This works quite often, and I don't even have a sister. Grin
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#6
I also got a used machine from "Second Wind", as I had problems with my insurance. It was cheaper to buy from Second Wind than to pay the monthly payments on a new machine. It arrived quickly and looks as if it were never used. If you have to go the buy your own route, I found them to be super helpful and they have good prices.
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#7
(07-16-2012, 05:26 AM)hmm--- Wrote: I also got a used machine from "Second Wind", as I had problems with my insurance. It was cheaper to buy from Second Wind than to pay the monthly payments on a new machine. It arrived quickly and looks as if it were never used. If you have to go the buy your own route, I found them to be super helpful and they have good prices.

I almost bought mine from Secondwind too, but I found one on my local Craigslist with only 140 hours on it for $300, and the seller threw in a couple masks as well. And I didn't have to deal with prescriptions.
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#8
Not all HMO's are the same. Mine approved my S9 Autoset, after I used CPAP for 3 weeks without success. In my case, my sleep study did not include a titration because I only slept for the last 2 hours. I was given the CPAP and told to use it for a month and return for the titration study. The machine was set for an arbitrary 7.0. After 3 weeks of using the CPAP and seeing no improvement, I begged for an autoset. I told them that my returning for a titration study was not going to give them the pressure settings I was likely to need, since I am an extremely light sleeper to begin with and can't sleep in strange places. The DME served as my go between with the sleep doctor, who understood the logic of my argument. They exchanged the CPAP for the Autoset.
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#9
(07-15-2012, 04:30 PM)Winkler3 Wrote: Hi Everyone,
I have recently been diagnosed with OSA.
After 2 weeks of waiting for the authorization, I just got a letter from my insurance co.
They are denying authorization for the auto pap that my sleep Dr. prescribed (I talked him into it).
The letter stated that I have to fail on a regular CPAP machine before they will authorize an auto pap.
This seems funny, because they pay by the code and both the CPAP and APAP use the same code.

Has anyone else ran into this?
Any advise would be appreciated.

I certainly do not know this for a fact, but my bet is that your DME Provider is the one that talked the insurance company out of providing you with the APAP.

When I got my 2nd machine almost 9 years ago, I was replacing it because my 1st machine was broken (but fixable) & I had it for 5 years (almost to the day).

Since I was replacing my machine anyway & I did NOT like my DME Provider, I decided to try to deal with another provider.

I had already talked to my insurance company & they had agreed that although my 1st machine could be fixed, it was already 5 years only & it could die at any point. So spending money for repairs on a 5 year old machine just did not make sense (both to me & to my insurance company).

About a day later, the DME Provider called me & said that my insurance had refused to get me a new machine & that I would have to have the old one repaired. The DME provider had convinced a 2nd person at my insurance company of that.

So, I called my insurance company, talked to yet a 3rd person who aggreed with the 1st person & said she would contact the DME Provider & that I could in fact get a new machine.

Another day goes by & I get another call from my DME Provider.
She had convinced a 4th person at my insurance company not to give me a new machine.

So, I went back to my previous DME Provider & got my new machine the very next day.

You know - A bad DME Provider can look a lot better when compared to a really bad one.

About a week later, the owner of that 2nd DME Provider called me to ask why I had decided not to deal with them.
I told him the entire story.
He said he would check it out & call me back.
He did call me back & said that ex-employee was just plain wrong.
He offered me a hefty discount on a new machine.
He understood the ramifications of not satisfying an insured in a self-insured plan of over 10,000 people in a city of only 300,000.
But unfortunately I already had a new machine & certainly was not going to start that process all over again.

The owner of the 2nd DME Provider was lucky because I had not even bothered reporting that problem either to the insurance company or the insurance committee of the self-insured plan.

Although it is a self-insured plan, it is administered by Blue Cross / Blue Shield & BC/BS does provide catastrophic coverage over $ ??

Moral of this story is:
Even if your DME Provider says they have your best interest in mind in everything they do - Trust, but verify !
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#10
We don't have that problem in Australia - the Insurance companies pay $500 flat refund towards whatever machine is bought... and nothing toward mask, hose etc... and they even quibbled about that when I lodged my claim...
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