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CPAP to Bi-pap
#1
My husband was diagnosed with sleep apnea in August of this year and put on a CPAP machine. We have BCBS of Alabama coverage and had a 200.00 deductible which we have paid. In 6 weeks, he was to take the chip back for the DME to transmit info to the doctor to make sure that he was getting the proper air supply. Per doctor, it was not working as well as we had wanted. Therefore on 11/4, the doctor had him to have another sleep study using the bi-pap machine. On the cpap, he has 120 episodes where he stopped breathing and O2 level was at 64%.

On the Bi-pap machine, he had 10 episodes, not sure on the o2 level, but the doctor was certain that the bi-pap machine is what he needed. However, BCBS of AL is not wanting to pay for the new machine stating it is not medically necessary. The DME company is filing an appeal with all documentation showing that he did improve on the bi-pap machine.

Has anyone had this to occur? I am so afraid insurance will not pay and we cannot afford to purchase a machine (2400.00) and rental would be 200.00 a month which we can afford either. Any advice and prayers are appreciated that this will somehow work our.
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#2
(11-13-2013, 02:02 PM)angie35016 Wrote: On the Bi-pap machine, he had 10 episodes, not sure on the o2 level, but the doctor was certain that the bi-pap machine is what he needed. However, BCBS of AL is not wanting to pay for the new machine stating it is not medically necessary. The DME company is filing an appeal with all documentation showing that he did improve on the bi-pap machine.
Hi angie35016, welcome to the forum
Its a medical necessity, the guidelines states that if CPAP (E0601) been tried and proven to be ineffective than patient can be switched to Bilevel (E0470). PAP Documentation Requirement Revision - Ineffective Therapy on E0601
http://www.medicarenhic.com/dme/medical_...0_pap2.pdf

http://www.resmed.com/us/documents/10132..._sheet.pdf

Best of the luck to both of you

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#3
I would get the doctor as well as the DME involved in the appeal. It's the doctor who needs to be writing the letter of medical necessity since it is the doctor who is prescribing the new BiPAP machine.

It is also worth your time to call BCBS and find out directly from them exactly what the appeals process consists of, exactly what documentation you, the doctor, and the DME need to be providing, and when to expect a decision. It is worth trying to pin them down on how they have arrived at their decision that the BiPAP is not medically necessary given that hubby is still having far too many events with far too much O2 desaturation while using the CPAP machine. That said, I would not actually expect to get any real information out of BCBS about how the decision was made, but it's still worth asking them to justify that decision in light of the fact that your hubby has documented evidence that the CPAP is not doing him any good and a sleep study that points to a bipap as potentially treating his problem very well.
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#4
(11-13-2013, 02:59 PM)zonk Wrote:
(11-13-2013, 02:02 PM)angie35016 Wrote: On the Bi-pap machine, he had 10 episodes, not sure on the o2 level, but the doctor was certain that the bi-pap machine is what he needed. However, BCBS of AL is not wanting to pay for the new machine stating it is not medically necessary. The DME company is filing an appeal with all documentation showing that he did improve on the bi-pap machine.
Hi angie35016, welcome to the forum
Its a medical necessity, the guidelines states that if CPAP (E0601) been tried and proven to be ineffective than patient can be switched to Bilevel (E0470). PAP Documentation Requirement Revision - Ineffective Therapy on E0601
http://www.medicarenhic.com/dme/medical_...0_pap2.pdf

http://www.resmed.com/us/documents/10132..._sheet.pdf

Best of the luck to both of you

I read the first link and it listed 3 reasons for switching. It didn't say if all 3 had to be met or if it could be one or two of those listed. Anyone know?

IMHO, just because AHI's are controlled doesn't mean that one doesn't need BIPAP and just because AHI's are higher than 5 doesn't mean one needs BIPAP but if one does need it, it shouldn't just depend on AHI's being controlled. There is more to it than that.
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#5
Hi angie35016,
WELCOME! to the forum.!
What has been said so far.
Hang in there for more responses to your post.
trish6hundred
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#6
(11-13-2013, 04:57 PM)me50 Wrote:
(11-13-2013, 02:59 PM)zonk Wrote:
(11-13-2013, 02:02 PM)angie35016 Wrote: On the Bi-pap machine, he had 10 episodes, not sure on the o2 level, but the doctor was certain that the bi-pap machine is what he needed. However, BCBS of AL is not wanting to pay for the new machine stating it is not medically necessary. The DME company is filing an appeal with all documentation showing that he did improve on the bi-pap machine.
Hi angie35016, welcome to the forum
Its a medical necessity, the guidelines states that if CPAP (E0601) been tried and proven to be ineffective than patient can be switched to Bilevel (E0470). PAP Documentation Requirement Revision - Ineffective Therapy on E0601
http://www.medicarenhic.com/dme/medical_...0_pap2.pdf

http://www.resmed.com/us/documents/10132..._sheet.pdf

Best of the luck to both of you

I read the first link and it listed 3 reasons for switching. It didn't say if all 3 had to be met or if it could be one or two of those listed. Anyone know?

IMHO, just because AHI's are controlled doesn't mean that one doesn't need BIPAP and just because AHI's are higher than 5 doesn't mean one needs BIPAP but if one does need it, it shouldn't just depend on AHI's being controlled. There is more to it than that.
The connector word is OR. That usually means only one of the three conditions needs to be met. The severity of the problem may come into play, however. For example, if the only problem is "failed to improve sleep quality", the patient (or his/her doctor) may have to provide some actual evidence that the sleep quality actually decreased rather than simply didn't improve---if the symptoms have improved and the AHI is under control.

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#7
I have no clue how I MISSED the word or Dont-know

thanks
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#8
(11-13-2013, 02:02 PM)angie35016 Wrote: On the cpap, he has 120 episodes where he stopped breathing and O2 level was at 64%.

On the Bi-pap machine, he had 10 episodes, not sure on the o2 level, but the doctor was certain that the bi-pap machine is what he needed. However, BCBS of AL is not wanting to pay for the new machine stating it is not medically necessary.

Hi angie35016, welcome to the forum!

Keep in mind that two appeals are often needed.

The first appeal is often just an internal review by the insurance company itself, to verify that they followed their own rules.

I think the second appeal would include a health insurance regulatory agency. That's the one that counts.

Make sure you read the denial letter carefully to see if all appeals must be submitted in writing to protect your rights.

Also, at the top of every forum page is a link to our Supplier List. If you end up buying a machine without help from BCBS you could pick up from Supplier #2 a slightly used but excellent Respironics DS760 BIPAP Auto Machine for $699 plus $90 for humidifier plus $75 for heated hose kit, or $865 total. Or you could pick up a slightly used but excellent ResMed S9 VPAP/BIPAP Auto for $769 plus $90 for humidifier plus $51 for heated hose, or $910 total. If you can re-use your present humidifier and heated hose, you would not need to buy that part again.

Good luck and take care,
---- Vaughn
Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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