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Wife did not pass compliance
#1
ok - so my wife has been using her machine for almost 2 months now - every night, she got a letter from the insurance the other day, saying they are no longer going to pay for the machine, because she did not use it enough during the first month. Their where a few days over a long weekend where she could not use the machine - got got sick, and could not breath out her nose - and since the only mask that she is a nasel, she could not use it - and she could not get into the DME to exchange the mask, they where closed for a long weekend, so she had 3 days that should could not use the machine at all.

They said that she used the machine for over 4 hours per night 61% of the time, over a 27-day period - so how much of a different did loosing those 3-day really make in her percentage, and it does not sound like they looked at the full 30-day period - but only 27 days?

She is going to filling out all apeals paperwork - which is a lot, now in the meantime - we need to figure out who is going to be paying the $130 a month for the machine rental and so forth.

All this happened just a fer days after we had decided to see about getting to a S9 autoset, and that would involving going to a different DME - but now we are just waiting till we get work on weather her appeal aoo goes through?

I am sure others out their have dealt with this - how much of a battle is it to get the appeal to be approved, and things OK with the insurance? We do have her regular doctor on her side, and can vouch for her being sick - so that should not be an issue?

What other documents, and so forth should we be getting together to help us out? if their are any?

Thanks for any input you all can give to help us get me wife back on her machine - we do know that if insurance will not pay for it - then she can't have it - their is just no way we can pay an extra $180 a month total for the machine and humidifier, plus masks, hoses, filters, and all the other stuff.

Thanks,

Scott
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#2
Sorry about your wife. I don't how this insurance system works but she need using her machine ask the doctor for help.
If they take the machine you can buy a gently used S9 Autoset from secondwindcpap (Supplier #2) or PRS1 Auto for $400 and is just as good
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#3
(06-22-2012, 05:56 PM)zonk Wrote: Sorry about your wife. I don't how this insurance system works but she need using her machine ask the doctor for help.
If they take the machine you can buy a gently used S9 Autoset from secondwindcpap (Supplier #2) or PRS1 Auto for $400 and is just as good

The doctor may have more luck with the appeal if he's willing to help. He may know more about the system and his words may carry more weight.
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#4
I ran into my own insurance problem. There was only one DME in-network with a 15% co-pay--but they tried to defraud my insurance company by submitting a claim before they ever set up an appointment with me. Fortunately, my insurance company called me to verify whether I had had my DME appointment. I dropped them since I felt it was unsafe to do business with them, but that left me with a 40% out-of-network copay and a new deductible. I realized that I could do better by bargain-hunting, so I turned to Craigslist. Anyway, I am now out of work so I lost my insurance coverage (but insurance paid for my sleep study). Going out-of-pocket turned out to be less expensive than using a shady DME, even after purchasing two machines.
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#5
(06-22-2012, 05:56 PM)zonk Wrote: Sorry about your wife. I don't how this insurance system works but she need using her machine ask the doctor for help.
If they take the machine you can buy a gently used S9 Autoset from secondwindcpap (Supplier #2) or PRS1 Auto for $400 and is just as good

Ya, I think with the docs help, she can verify that my wife could not use the machine for several days because she could breath out her nose - and that is the only option with her mask - seems like they would take that into account. BTW - we are in Oregon with the oregon health plan here
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#6
Well, if they only looked at the results using the 27 day period and(excluded sick days), then they were a bit liberal with the percentage. If they were to use the total of the 30 days of the month; then it would obviously be less then 61% if they added three days of no usage. However, we don't know exactly how they computed the percentage.

It is my opinion, that the ("over 4 hours a night") or ("at least 4 hours a night") of compliance is extremely liberal to me. Insurance companies are a business and as such need to insure that their coverage is beneficial to making a profit.

I agree with (Archangle), that perhaps your physician can help your situation with some professional letterhead involvement.

If there are some reasons that she can not use the CPAP for more then 4 hours a night, then perhaps a visit to the sleep doctor or DME to establish some help is needed. More then 4 hours of quality sleep a night is needed to help our bodies rejuvenate and rest.

If your insurance company will not continue your CPAP coverage, then as several posters have suggested, perhaps a purchase from an online seller is appropriate.
Yesterday is history; Tomorrow is a mystery; Today is a gift; Thats why its called "The Present".
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#7
For future reference, she can continue to use CPAP, even when congested. I have nasal pillows and have yet to have a problem where I could not use the mask, even when I lay down completely blocked. The pressure from the CPAP keeps the nasal passages clear although I do wake up hacking stuff up that was blown down. And, as soon as I take it off, I am congested again.
PaulaO2
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#8
If you missed 3 days out of 27, you'd be compliant 24 days out of 27, which is 89%. Even if they said you were compliant for 24 days out of 30, that'd be 80%. No way to see how they got 61% out of that!

I would advise you to contact the provider of the machine and ask them why the insurance company is doing this to you. They deal directly with insurance companies all the time, so they should be in a position to be able to help you. It's in their own best interests to do so, as the insurance company is paying them directly.
Sleepster
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#9
Thank everyone for the posts - I went and looked at her card with Rescan today - and found some very interesting numbers on thier - not what the insurance Co. is claiming that is for sure.

Here is the screenshot of her 30-day compliance review window:


[Image: resmed.jpg]

So unless I am reading this totaly wrong - between the dates of April 3, 2012 - May 2, 2012 she used the machine at least 4 hours a night 83% of time time!! -- that is a lot different than the 61% than the insurance Co. is claiming.

Someone please correct me if I wrong - so I don't make a fool out of myself come monday


Scott
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#10
You,re spot on Well-done
Your wife used the machine 4 days less than 4 hours a day plus 1 day not used the machine
4 days +1 day = 5 days = 17%
30 days = 100%
25 days = 100% - 17% = 83%
Also if you check the summary graph - total usage - there is red line at 4 hours compliance threshold

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