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What does it take to get insurance to replace a machine after 5.5 years?
#1
My insurance company just refused to cover a replacement CPAP machine for the Respironics Sleepeasy base model that I've had since 2009. They (Anthem BC/BS) kept asking the doctor's staff if the old one was broken or not. She said no, it wasn't broken, but that it has been 5.5 years and the patient (me) is ready for new technology. The pre-cert was referred to an insurance nurse, and then to a doctor. I was asking for a new machine, mask, and tubing, and all seems to have been denied. Does anyone know a) how I can find out exactly what I am entitled to, and b) what is the criteria for getting a replacement mask after 5.5 years? I do not want to rent a machine; I am now an experienced user and want to buy one outright, preferably over the Internet. Thanks in advance.
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#2
If you want to pay out of pocket and bypass insurance, all you need is a prescription for the machine and mask. The hose, filters, etc do not need a script. The script can be written by any doctor, it does not need to be a sleep doctor. The online supplier you choose will help you with what needs to be on the piece of paper. I suggest you check out Supplier #2 from our Supplier's List (link at the top of every page). They sell 'gently used' and open box machines at decent prices.

If you would like the insurance company to pay, they no longer will automatically buy a new one just because it is a certain age, even if you would get better treatment from a new one. They don't care. They only see the money. The problem is they asked the doctor's staff, not the supplier. A supplier (DME) would have padded the forms some with elaborations such as "noisy machine is indicative of failing compressor". But a DME is not going to fail it for you without there being a financial reason for them to do so.

It is all about the money. Who cares if the patient would be healthier, right? Who cares if heart surgery from using an inadequate CPAP is fifteen (or so) times more expensive than a new CPAP? It's all about the money right here, right now.
PaulaO2
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#3
(11-05-2014, 08:39 PM)Bubblace Wrote: Does anyone know a) how I can find out exactly what I am entitled to, and b) what is the criteria for getting a replacement mask after 5.5 years? I do not want to rent a machine; I am now an experienced user and want to buy one outright, preferably over the Internet. Thanks in advance.
Welcome to the forum, Bubblace
I don't know about your entitlement but can you check with your insurance company
Coverage under Insurance and Medicare and FAQs
http://www.apneaboard.com/wiki/index.php...6_Medicare

As for buying on-line, ResMed S9 AutoSet and Phillips Respironcis System One Auto 560 are the two most popular auto-cpap

Now there is a new machine ResMed AirSense 10 AutoSet For Her, does 3 modes ... CPAP, AutoSet, AutoSet For Her (female specific algorthim)

ResScan (windows only) support S9 AutoSet, AirSense 10 AutoSet For Her
SleepyHead support them all, works windows and Mac computers

Supplier #2 seem to have the best prices, example: New, Open Box Respironics System One DS560 REMstar Auto w/ Heated Humidifier $549.00 ... *Thermal Tubing Conversion Kit Included!
http://www.apneaboard.com/forums/Thread-...plier-List
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#4
Thats kind of strange but I guess insurance is different from company to company. Im on Medicare thru an advantage plan. Not sure if I allowed to say which one.

Talked to them when I started this cpap thing. Talked to the DME. Both assure me and its in my book of benefits also that in 13 month I own this machine with a 20 percent co pay every month. At 5 yrs is their "reasonable expected useful life" of the machine and I start over with a new machine, and the 20 percent copay for 13 months with my lifetime prescription and my GP signing off I benefit from the use of the machine.

I asked did it have to be broken etc and was told no as they consider the machine on its last legs at that point and not reliable as to being able to produce prescribed pressures.

Guess other companies are different.
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#5
Hi Bubblace,
WELCOME! to the forum.!
What Paula said.
Hang in there for more responses to your post.
Best of luck to you on your CPAP machine decision.
trish6hundred
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#6
When I started back in 2009, the DME made house calls and physically dropped off the machine to me as well as taught me how to use it. They no longer do that, and given that they are an hour away from me, I decided an Internet purchase would be a lot simpler. But turns out it's not - because using a physical DME seems to be the only way the insurance wants to go - but I don't have a DME near my house - and so we go round and round!

Don't they have to have a concrete reason for turning me down? How do I find out what that is? And don't I get some sort of appeal?
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#7
(11-05-2014, 09:33 PM)Bubblace Wrote: When I started back in 2009, the DME made house calls and physically dropped off the machine to me as well as taught me how to use it. They no longer do that, and given that they are an hour away from me, I decided an Internet purchase would be a lot simpler. But turns out it's not - because using a physical DME seems to be the only way the insurance wants to go - but I don't have a DME near my house - and so we go round and round!

Don't they have to have a concrete reason for turning me down? How do I find out what that is? And don't I get some sort of appeal?

Well they want to know if its broken. A slipped tank of water or a ball peen hammer would fix that. Thinking-about

NO NO IM KIDDING. Honestly I thought about all insurance went by Medicares standards. They sure do when it comes to getting the first machine. But apparently not all do. Id have no idea except get your doc and DME to argue with em long enough.

I would guess that if your Doc says something is now medically necessary for you that your machine doesnt have they would have no choice. But thats a guess.

Or you could sit on the machine and tell em you passed out from lack of O2 from poorly treated apnea and fell on it. IM KIDDING AGAIN.

Dont-know

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#8
These are all questions specific to your specific insurance company and your specific policy. If they violate the terms of their policy with you, then there probably is recourse in whatever state you are in. But the place to start is with the insurance company to find out what they will or will not do, and whether or not you can fulfill their requirements. Then if not, being as how they are no doubt a responsible and reliable insurance company, they probably do have an appeals department that you can go pound sand in.
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#9
Seems to me that after 5.5 years your machine must be making some funny noises right? Seems like the pressure feels like it is moving up and down, right? And when you wiggle the power plug just right doesn't it stop working completely? Certainly sounds like that old machine is on it's last legs and not working right. I'll bet the air even has started to take on a funny smell, possibly a burned smell? Well at least it sounds like that to me..... Maybe it is broken, sometimes maybe you have to go along to get along.
If everyone thinks alike, then someone isn't thinking.
Everyone knows something, together we could know everything.
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#10
I truly appreciate the humor in these posts. You guys have made me feel a little better about my situation. Thank you!
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