Question:
held hostage by my cpap machine....
I finally received my prescription for the cpap machine when the company informed me that my insurance co. us health care aetna doesnt cover the machine . i have only a couple of options one. call the company and request special coverage for the machine or try to see if my veteran status will get the machine thru the va or pay for it out of pocket which im not in a position to pay for at this time . my tentative date is july 29th and i cannot get a clearance letter from my pulmonary dr. with out having been on the machine for a week or two can any body help me .signed trying to get a date of surgery before the end of the month.before my surgeon goes on vacation. — curt P. (posted on July 5, 2002)
July 5, 2002
I just got a new BiPap and it cost 1800.00! Luckily it was covered. You
must be so stressed! I'd do both if I was you. Request coverage and try
thru VA. Good luck! :)
Sandi
— goodgal
July 5, 2002
From the Aetna US Healthcare Site
(http://www.aetna.com/cpb/data/CPBA0004.html - Coverage Policy Bulletin 4 -
Obstructive Sleep Apnea & Treatment)
CPAP is covered as DME [durable medical equipment] for the treatment of OSA
when either of the following criteria are met:
Sleep Study Results:
Patient's Apnea-Hypopnea Index (AHI) (also called the Respiratory
Disturbance Index or RDI) is greater than 15;
OR
AHI > 5 and < 14 and one or more of the following are met:
1) Excessive daytime sleepiness (documented by either Epworth >10 or
Multiple Sleep Latency Test (MSLT) <6);
2) Documented symptoms of impaired cognition, mood disorders, or insomnia;
3) Documented hypertension (systolic blood pressure > 140 mmHg and/or
diastolic blood pressure > 90 mmHg);
4) Documented ischemic heart disease;
5) Documented history of stroke;
6) Greater than 20 episodes of oxygen desaturation < 85% during a full
night sleep study, or any one episode of oxygen desaturation < 70%.
Note: The AHI (Apnea-Hypopnea Index) is equal to the average number of
episodes of apnea and hypopnea per hour and must be based on a minimum of 2
hours of sleep recorded by polysomnotraphy using actual recorded hours of
sleep (i.e., the AHI may not be extrapolated or projected). For purposes of
this policy, apnea is defined as a cessation of airflow for at least 10
seconds. Hypopnea is defined as an abnormal respiratory event lasting at
least 10 seconds with at least a 30 percent reduction in thoracoabdominal
movement or airflow as compared to baseline, and with at least a 4 percent
oxygen desaturation.
BiPAP, DPAP, VPAP, and AutoPAP are covered as DME for patients who are
intolerant to CPAP. These alternatives to CPAP may also be covered for OSA
patients with concomitant breathing disorders, which include restrictive
thoracic disorders, COPD, and nocturnal hypoventilation. Aetna covers
humidifiers for positive airway pressure devices. However, heaters for
these devices have not been shown to be of clinical benefit and are
considered not medically necessary and are not covered.
Consistent with Medicare Part B guidelines, supplies (e.g., mask, hose,
rings, and seals) are covered that are necessary for the effective use of a
covered positive airway pressure device. Aetna covers replacements, repairs
and maintenance of durable medical equipment that is not provided for under
a manufacturer's warranty or purchase agreement when it is functionally
necessary and appropriate.
Upon individual review, positive airway pressure devices may be covered as
a form of noninvasive ventilation for patients with lung disease without
OSA. Requests for these devices for noninvasive ventilation of patients
with lung disease should be forwarded to the medical director for review.
**********So, what I would do is find out WHY Aetna-USHC won't cover the
machine (did you not meet one of the criteria). If you met the criteria
as listed, then I would appeal the decision - quoting their own CPB.
Hope this helps. PS - I had BC/BS at the time I got the CPAP machine.
My doctor at the time documented that this was going to be a long-term
condition, so BC/BS bought the machine for me vs renting it. Maybe while
you are working the insurance issue, you may be be to rent a CPAP machine
for a month or two. You'll have to pay for the supplies like tubing and
nose plugs/mask, though.
— John Rushton
July 5, 2002
Curt - I work for a DME company that supplies CPAP machines - if your
insurance denied, it was most likely due to the results of the sleep study.
If you met Aetna's criteria and they still denied then it is possible the
company that submitted the authorization request did something wrong. The
usual ins co criteria is 30 episodes of apnea in 6-7 hours of recorded
study time. Medicare just changed their rules on that to allow for an
apnea-hypopnea index or RDI of 15 or greater which is MUCH more lenient.
Call and ask Aetna if they go by MEDICARE guidelines - most insurance
companies base their rules on those guidelines - if they say yes then you
stand a better chance if/when you decide to appeal the denial - which you
most certainly should do. I have had our patients get denied in the past
when they didn't meet the medical necessity criteria and then they end up
getting approved when they appeal - you need to have your physician write
you a letter to submit to them and you also need to write your own appeal
letter - one that tells them of all the problems you are having pre-CPAP,
and all the benefits you will have if you are able to use the device. Make
sure you get a copy of your sleep study to submit also - you also might be
interested just to read it - it might shed some light on some of your sleep
problems and let you know how severe you really are. As a last resort -you
could ask for private pay arrangements - we do them for our patients and we
give them a great discount as long as they don't forget to make the
payments. You might be able to buy a machine on the internet fairly
cheaply also - but then you won't have the benefit of a company to set the
pressure for you and to properly fit your mask (and masks can cost up to
$200 each!) Ask the DME company if they have any "demo" masks to
sell you - we sometimes have to open 3 mask packages to do a fitting on a
patient - and once the package is opened we can't sell that mask as
"new" anymore. Also ask them if they have any used machines they
can sell you - CPAP's can last for as long as 5-7 years if you take care of
them - and most returns are from short-term patients who became
non-compliant and gave up. If you need any more help, feel free to e-mail
me - I'll do what I can. Good Luck!
— Kim A.
July 5, 2002
I am not sure why Aetna would do that. If you have had a sleep study and
you are defenitly diagnosed I don't get it. I have Aetna and I was
approved and they bought and paid for the entire machine. If you are going
to have surgery by the end of the month do you still need the cpap machine?
I have mine, rarely use it. I am tired still during the day but I am
having surgery on Aug 13 and that stupid machine bugs me so I always rip it
off in the middle of the night without even noticing it. Anyways, call
Aetna and find out what the heck is going on!!!
Good Luck...hugs
— Michelle J.
July 6, 2002
Curt, if the insurance company refuses to pay for your c-pap,
which sounds crazy in the first place, then please contact your
local VA office. They may be able to help you in many other
ways too. That's what they are for, and I am a firm supporter
of our nation's veterans, no matter when or how they served.
As a matter of fact, I would just go ahead and contact them now!
Good luck! Ginger
— Ginger N.
July 6, 2002
This answer is to Kim who posted below about CPAP machines lasting 5-7
years if you take care of them.
I must take *extra* good care of mine since I got it back in 1993 and it's
working just fine...
— John Rushton
July 6, 2002
I had to rent my cpap because my Kaiser insurance did not have DME (durable
medical equipment) coverage. The cost was $66.00 a month. I rented the
machine from January 2002 until just about a month after my surgery (May
2nd 2002). My sleep apnea was GONE after I lost the first 30 lbs. If you
end up having to rent, I hope you'll be this lucky. But I also agree, check
with your VA first. It would be so helpful if they could cover it. $66.00
a month isn't cheap. Hugs, Joy
— [Deactivated Member]
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