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decided on a machine... providers wont order under insurance or current prescription
#1
hi all... just found this board while trying to figure out if i am asking too much.

i have a 4 year old machine that the sleep doc wanted me to try and repair instead of ordering a new machine. i have new insurance so i said no to that.

i looked and compared and decided on the aircurve 10 vauto. my treatment has changed a few times since my initial and follow up sleep studies.

couple this with the 5 year replacement cycle of the insurance company and i opted for a unit that has additional capabilities that are not needed now, but likely in the future.

all of the dme providers so far say its a special order item that costs 5k for them to get and it is not covered by insurance.

i call my insurance and they say that there is nothing that stands out as to why this would be denied.

my thinking is that the dme cant make all that much money on it and thats why they wont order or are quoting 5k out of pocket. is that true or am i over thinking this?

i am compliant in terms of use with at least 4hrs a night over 23 of 30 days.

is this a rare machine or too much to ask for?

i wish i saw this board when i initially started cpap treatment... it would have save me a lot of time and money back then....
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#2
Switch suppliers. There is no such thing as a special order CPAP. They don't custom make them per user or design them on the fly. They are mass produced. They are so mass produced that CPAPs all have the same insurance codes.

CPAPs and autoPAPs have one code
biPAPs have another code
ASV PAPs (those used to treat central apnea) have another

No matter the machine and no matter the bells and whistles it does and does not have, the insurance pays the same amount based on that code. So if the machine you would like to have has more bells and whistles and the supplier would "lose" money, then yeah, they're going to try and talk you out of it.

Now, the problem is you are requesting a bilevel. Those things cost more and most insurance will balk at paying for one without you first "failing" regular CPAP. Is your current machine a bilevel? if it is, then there will be no problems. If it isn't, they may say on the phone, sure, we'll pay for it, but in reality, they may refuse at first.
PaulaO2
Apnea Board Moderator
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Breathe deeply and count to zen.

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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#3
Hi cpap_anonymous,
WELCOME! to the forum.!
Much success to you as you continue your CPAP therapy.
Hang in there for more responses to your post.
trish6hundred
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#4
Using them as an example, Medicare pays about twice as much for a bilevel like the AutoV than they do for a single level CPAP (and twice as much for an ASV as a bilevel). The same is probably true for your insurance company. That's about the difference in cost if you order on line out of pocket. Unless your current sleep study and prescription justify a bilevel, or you've failed with a single-level CPAP, they aren't going to pay for it regardless of what you want. You could push for an AirSense 10 AutoSet in the same single-level category. The DME will get paid the same for that as a brick (same billing code), so they may not even want to give you that.
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#5
cpap_anonymous,
I believe that the only way a supplier will order is if you have a perscription from your Doctor for a
Bilevel. If you are not currently using that type of machine and your script is not for a bilevel, then the provider probably won't order what you want.
Bottom line...get the right script from your doctor.
OpalRose
Apnea Board Moderator
www.ApneaBoard.com

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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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#6
(04-15-2015, 01:30 PM)cpap_anonymous Wrote: hi all... just found this board while trying to figure out if i am asking too much.

i have a 4 year old machine that the sleep doc wanted me to try and repair instead of ordering a new machine. i have new insurance so i said no to that.

i looked and compared and decided on the aircurve 10 vauto. my treatment has changed a few times since my initial and follow up sleep studies.

couple this with the 5 year replacement cycle of the insurance company and i opted for a unit that has additional capabilities that are not needed now, but likely in the future.

all of the dme providers so far say its a special order item that costs 5k for them to get and it is not covered by insurance.

i call my insurance and they say that there is nothing that stands out as to why this would be denied.

my thinking is that the dme cant make all that much money on it and thats why they wont order or are quoting 5k out of pocket. is that true or am i over thinking this?

i am compliant in terms of use with at least 4hrs a night over 23 of 30 days.

is this a rare machine or too much to ask for?

i wish i saw this board when i initially started cpap treatment... it would have save me a lot of time and money back then....
I'm not sure were your located, but seems like a bad story to me.
I'd check with your insurance company again for a new DME, or see if you can buy the $800 dollar one's on line.
And no it's not a rare machine probably the most popular right now.
(Unless there some kind of shortage on this model right now?)
Good Luck!
Sleep-well
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#7
How did this workout for you cpap_anonymous?
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#8
(04-15-2015, 01:30 PM)cpap_anonymous Wrote: is this a rare machine or too much to ask for?

i wish i saw this board when i initially started cpap treatment... it would have save me a lot of time and money back then....

It's about $1,700 online, as opposed to a regular APAP which runs about $700 online.

If you're currently doing well with your APAP, they're unlikely to pay more than double unless there's some medical reason your doc can prove.



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#9
Hi all. Thanks for explaining. I haven't heard any of this from the insurance, dr, or dme provider.

the prescription did request the model I requested, but set only for a specific pressure. The Dr was ok with that part at least. Since my treatment doesn't require it that is where the provider is balking at I guess. Still the out of pocket cost if I want it is still 5k. I told the dme to cancel the order and I would look into my options. This one was the only one willing to order it though so I am not sure why I can't get it for less than that.

In the mean time I am going to make my current machine last as long as I can.

Thanks for explaining everything that the Dr and dme provider should have at the beginning.
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#10
It would help us provide additional suggestions, if you would provide your location in your profile. Different countries, different rules.

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 OPINIONS ONLY AND NOT NECESSARILY STATEMENTS OF FACT.
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