Insurance denies new machine

[jimc2]

Looking for some guidance here.

I have been using my machine for a bit over 5.5 years. I believe the insurance I have now is NOT the same company I had when I got the machine. Oxford/United Healthcare is who I have currently. My current machine doesn't have cell data nor have I mailed in my card in years.

My doc finally jumped through whatever hoops (been about a month to the day almost) the insurance company wanted and it got rejected today. I provided a sleepyhead report which he forwarded onto them. They said if the machine is working fine they will not authorize/cover a replacement and wait till it fails. I would rather have a new machine in place before it fails. Seems to be running well but it is over 5 years old and I do use it EVERY night.

I THINK it would be a few hundred dollars cheaper though insurance but can't seem to get a straight answer on what exactly my cost would be. I remember when I did this previously they told me a higher amount then it ended up being. Even the day I took delivery of my machine they were saying one price but when the bill finally went through insurance it was cheaper.

Insurance said my cost through them would be $550 to $660 (if it was covered). Maybe a bit less since I have met my deductible for the year. For $749 I can just buy the machine (Dreamstation with heated humidifier) at cpap.com. Already have a prescription on file with them that should be good. I also wouldn't have to take time off work to meet with the DME.

Before all this my initial thought was just buy the machine from cpap.com and not deal with insurance nonsense.

I have enough in my Flexibile Spending to cover it but hate potentially spending hundreds more then I should.

For less then $100 I wouldn't hesitate going the path of least resistance.


Anyone deal with this before and have success with getting a new machine even though the existing one is working fine?

[Okie bipap]

I have not had that problem, yet. However, I do not want to take a chance on having to wait for my machine to be repaired, or wait for the insurance to approve a new machine when mine quits, so I purchased two spare machines (my wife and I both use the same model machines). I found one here on the forum and one on Facebook market. I often find them listed on the local Craig's List.

[Wulfman...]

Looking for some guidance here.

I have been using my machine for a bit over 5.5 years. I believe the insurance I have now is NOT the same company I had when I got the machine. Oxford/United Healthcare is who I have currently. My current machine doesn't have cell data nor have I mailed in my card in years.

My doc finally jumped through whatever hoops (been about a month to the day almost) the insurance company wanted and it got rejected today. I provided a sleepyhead report which he forwarded onto them. They said if the machine is working fine they will not authorize/cover a replacement and wait till it fails. I would rather have a new machine in place before it fails. Seems to be running well but it is over 5 years old and I do use it EVERY night.

I THINK it would be a few hundred dollars cheaper though insurance but can't seem to get a straight answer on what exactly my cost would be. I remember when I did this previously they told me a higher amount then it ended up being. Even the day I took delivery of my machine they were saying one price but when the bill finally went through insurance it was cheaper.

Insurance said my cost through them would be $550 to $660 (if it was covered). Maybe a bit less since I have met my deductible for the year. For $749 I can just buy the machine (Dreamstation with heated humidifier) at cpap.com. Already have a prescription on file with them that should be good. I also wouldn't have to take time off work to meet with the DME.

Before all this my initial thought was just buy the machine from cpap.com and not deal with insurance nonsense.

I have enough in my Flexibile Spending to cover it but hate potentially spending hundreds more then I should.

For less then $100 I wouldn't hesitate going the path of least resistance.


Anyone deal with this before and have success with getting a new machine even though the existing one is working fine?

Worked for me! Many times.
I never relied on my insurance provider to pay for my machines or other supplies. They did reimburse me 80% for my initial purchase, but that was it.


Den

.

[chunkyfrog]

EVERYBODY should have a backup, because nobody should have to go without
while insurance wheels grind to a halt.
I bought mine fron cpap.com--secondwindcpap.com is good, too.
Anywhere else may not have a warranty.,
Or be way overpriced.

[ChicagoGranny]

They said if the machine is working fine they will not authorize/cover a replacement and wait till it fails.

Most health insurance policies follow the Medicare guidelines for CPAP replacement. Under Medicare, you would likely not be eligible for a replacement machine unless your doctor would write a creative letter insisting your current machine no longer meets your needs.

More than five years
The replacement of an item past the five-year lifetime will
be considered in cases of irreparable wear if the item has
been in continuous use by the patient, on either a rental
or purchase basis, for the equipment’s useful lifetime.
• Irreparable wear:
– Irreparable wear refers to deterioration sustained
from day-to-day usage over time and a specific
event cannot be identified.
– In cases involving irreparable wear, the Reasonable
Useful Lifetime (RUL) of the equipment is taken into
consideration, and in no case can it be less than
five years old.
– Computation of the useful lifetime is based on when
the equipment is delivered to the patient, not the
age of the equipment.
– A physician’s written order is needed to reaffirm
the medical necessity of the item.
• If a PAP machine is replaced following the five-year RUL,
there must be a face-to-face evaluation by the treating
physician documenting that the patient continues to
use and benefit from the PAP machine. There is no
requirement for a new sleep test or trial period. Note:
If a DME item reaches its five-year life expectancy, is
in good working order and meets the patient’s medical
needs, it should not automatically be replaced.

https://www.resmed.com/us/dam/documents ... achine.pdf

Most of us have a backup machine. It would be great if you get a newer, data-capable, auto machine and keep your old machine as a backup. (New machines sometimes fail or get damaged.)

Hang around this thread a bit and someone should point you to some bargains.

[Janknitz]

Contact your insurance company and ask them to send you the "Evidence of Coverage". That is the actual contract between you and your insurer but you may not have ever seen it because you don't get it unless you ask. You can look in there for criteria for coverage of DME like CPAPs. If there's nothing in there that says that a machine they did not provide in the first place must fail before a replacement, then you should appeal the denial. If it's not in the EOC, it's not an appropriate reason to deny.

NOTE: If your insurer is a Medicare supplement, this will not apply, because Medicare's rules are they won't replace a machine unless there is a problem. But if this denial is from your primary insurer, you may have a good appeal.

[SewTired]

Your option is to file an appeal showing that cpap machines are designed to last for 15,000 hours. At that point, they are worn out to design capacity (someone here has a link to that- I just don't remember the thread). Yours is XXX hours. If you waited until it failed, you would potentially be without a machine for 2 weeks or more resulting in NO therapy, which is the reason why you have the machine in the first place.

If your machine has not reached 15,000 hours, chances are you will be barking up a tree for nothing, but I'd still give it a shot.

My DME uses the 15,000 hours as a replacement reason. Some people will just say that it 'makes a noise' and since Medicare won't repair something after 5 years, you can apply for a replacement new machine.

[jimc2]

Thanks everyone for the replies. As of a month ago my machine was at 13,468.8 hours. So I am not at 15,000 hours just yet. Would be another 200 days or so before I would hit that.

I will sleep on it but I am leaning towards just ordering the machine directly from CPAP.com. I got a 15% off coupon in the mail today along with my docs paperwork including prescription written for the exact machine I want which brings the machine down to $653. Which is the upper end of what insurance initially thought I would pay even with their help. I wouldn't get a mask I guess but otherwise would get the machine I want without the hassles. My P10 is pretty new and I have Swift FX as well as a backup.

My old machine has full data and would become my backup/travel machine.

I might try to appeal but might end up costing me about the same anyway.

[jimc2]

Most of us have a backup machine. It would be great if you get a newer, data-capable, auto machine and keep your old machine as a backup. (New machines sometimes fail or get damaged.)

Hang around this thread a bit and someone should point you to some bargains.

I don't travel much for work (or pleasure). Was out of town last week in your fair city. I actually dropped the bag with my machine in it in my driveway. It was only a foot or so drop. No damage. But I was like I wish I had my new machine already. I have to be out that way again later this year or early next. Want to have a travel machine for that trip.

[DavidY]

U$653 seems expensive for a Dreamstation Auto. That is the price here in Canada but in Canadian dollars. Check Amazon?

[Janknitz]

Thanks everyone for the replies. As of a month ago my machine was at 13,468.8 hours. So I am not at 15,000 hours just yet. Would be another 200 days or so before I would hit that.

I will sleep on it but I am leaning towards just ordering the machine directly from CPAP.com. I got a 15% off coupon in the mail today along with my docs paperwork including prescription written for the exact machine I want which brings the machine down to $653. Which is the upper end of what insurance initially thought I would pay even with their help. I wouldn't get a mask I guess but otherwise would get the machine I want without the hassles. My P10 is pretty new and I have Swift FX as well as a backup.

My old machine has full data and would become my backup/travel machine.

I might try to appeal but might end up costing me about the same anyway.

Getting insurance to pay is nice, but not having to deal with DME crap is priceless. So if you can afford it, go for it!

[chunkyfrog]

Not having to deal with DME or INSURANCE crap: PRICELESS!
Medicare seems lousy--unless you have had BCBS or UHC previously.
Just saying.
They have no concern for all the bodies in their wake.

[dreamingofdreaming]

I have United Healthcare and used this to purchase my machine this year. The cost for the machine, humidifier and tubing was very close to what they charge on cpap.com. They bill the insurance for all of these separately.

[ChicagoGranny]

I have United Healthcare and used this to purchase my machine this year. The cost for the machine, humidifier and tubing was very close to what they charge on cpap.com. They bill the insurance for all of these separately.

Do you have your EOB yet? What was the amount you had to pay? What was the amount UHC allowed (paid to the DME)?

[jimc2]

I have United Healthcare and used this to purchase my machine this year. The cost for the machine, humidifier and tubing was very close to what they charge on cpap.com. They bill the insurance for all of these separately.

Thanks for the info. My machine was delivered today. Not sure if I will get a chance to set it up tonight or not. I want to go through and see all the settings on the old and figure out what the equivalent is on the new.

Just glad I have a new machine and my old as a spare.