UPDATE on Getting Insurance Co. to Pay for New Machine

LONG . . .

First part is a repeat but explains "story" to any new readers.

Killing Me Softly . . .

E. Nan Edmunds - April 2007

For 10 years I have been in complete compliance in using a CPAP machine recommended as a result of a sleep study diagnosis of severe sleep apnea.

Although the CPAP therapy seemed to be working these past 10 years (I felt better and was less tired), not one person (medical or medical equipment company staff) had asked me if my sleep apnea was under control or if I was in compliance with the therapy.

I was not alarmed that my primary care physician did not inquire regarding my sleep apnea as I have been under the care of several different primary care physicians the past 10 years, albeit the same physician group. And, the same medical center where I receive my care and where I was also employed, went through a disruptive merger, then “demerger.” I believe my sleep records with the sleep study lab were lost when medical records went to the “other side.” The “sleep” (or is it asleep) doctor who reviewed my sleep study and prescribed my treatment remains in same office at the medical center where my sleep study was conducted.

And even though my insurance carrier allowed for a new mask/headgear/hose every six months, no one told me. After approximately 5 years when my nose mask, etc., was showing signs of wear, I called the DME (Wasserotts) who had provided the CPAP machine, etc. to ask what the procedure was to purchase/replace the nose mask and head gear and was told to come in to the facility (warehouse) where I was given a replacement paid for by my insurance carrier at that time.

Several years later when it was time for another replacement mask, I called Wasserotts to discover that Wasserotts had merged with Apria. I can only guess that no notices were sent to their client list. But then, maybe a notice was sent to those on record, as by this time my records were among the missing at Apria. I was supplied a new mask by Apria – no choice – just “here it is.” A short time later, an adjustable plastic part on that nose mask snapped so I “superglued” it. Of course it was no longer adjustable, but it did work. I mention the above “mask history” to point out that I am not a complaining pest who takes advantage at every opportunity.

Within the past year I began to notice some daytime tiredness. That, with falling asleep in the morning while in a sitting position (coffee cup in hand) and my husband’s keen observations of returned snoring (and a variety of other mouth/nose noises) alerted me to the possibility that perhaps my CPAP equipment was not working efficiently. At first I blamed the mask. So, just under 6 months ago, I requested a replacement nose mask from Apria. Again, I was given no choice – just handed a mask.

The snoring and other breathing noises continued with the new mask. I tightened the straps so snug that they left grooves on my face. The snoring did not stop. Then, weeks ago, my CPAP machine of 10 years began to make its own noises! It actually started to whine at me! What nerve! And then it began to rattle. I believed it to be dying. Oh no! What should I do now? Go online to see if there is a new and improved CPAP machine after ten years? Yes! There are new and improved machines, for example, a REMstar Auto C-flex! Hooray! I dutifully called Customer Service at Capital Blue Cross to find out if I could have this new machine as a replacement for my dying ten-year-old dinosaur. “Yes” I was told. I needed only to take a prescription from my doctor to a DME on their approved list of medical supply dealers.

My doctor, after reviewing my need for treatment for severe sleep apnea, noting the lack of medical follow-up and absence of monitoring the past ten years, wrote a prescription for a REMstar Auto C-flex with heated humidifier, Encore Pro Software and Card Reader and a Mirage Activa Mask with head gear. The REMstar Auto C-flex is a fully data capable machine and is key to my doctor closely monitoring my sleep apnea treatment for adherence and progress, or lack thereof. She also ordered an EKG and advised me to monitor my blood pressure at home on a more frequent basis.

The new prescription went to Apria. There it died. Apria said my 10-year-old, outdated CPAP machine might be repairable. I had to take the old machine to Apria for repair. Okay, maybe the machine can be repaired, BUT IT SURE CAN’T BE UPDATED.

I called my “friendly” Customer Service representative at Capital Blue Cross to protest. This time I was told that my doctor just had to call the insurance company with a preauthorization and all would be fine. The preauthorization was called in to Capital Blue Cross and to Apria.

RESULT: Apria and Capital Blue Cross continue to insist that the machine be repaired -- not replaced.

If that is the case, can Capital Blue Cross now have my ten-years-older body repaired and rejuvenated along with my ten-year-old machine? CPAP machines have been improved; I can’t say the same for my body. I would love to have ten years erased. Does someone really think that nothing changed internally in ten years that could affect sleep apnea? Who at Capital Blue Cross can claim that tissue doesn’t become softer and less resistant to a predetermined pressure? My mirror tells me that in ten years my face and neck have softened! Changes in weight affect the pressure required to treat apneas. My weight fluctuates. My blood pressure also fluctuates. Sometimes I sleep on my right side, sometimes my back and sometimes my left side—usually a little of each during the night. An auto-adjust machine can compensate for these moves--and weight changes--and mask leaks. An auto-adjust machine ADJUSTS to change. The ten-year-old CPAP machine DOES NOT.

I have a lifetime condition. I need to use this machine every night for the rest of my life. There is no way of knowing if the old machine will adequately treat my apnea. The old machine does not log any data except hours of usage; it is NOT capable of providing any data other than compliance. I have already proven my compliance with ten years of determined and faithful use. But what happens if my treatment does not go well? When I gain or lose weight? Start a new medicine? Change masks and need to know the actual leak rate? If I am no longer sleeping well? If I have headaches in the morning or develop other health problems? How can my doctor or I know for sure that I am not having apneas, or if my pressure needs to be adjusted? My doctor cannot adequately monitor my therapy if I do not have a machine with full data capability.

Respironics makes the REMstar Auto C-flex as well as the newer REMstar M Series Auto C-flex that records data including pressure profiles, number of minutes at a specific pressure level as well as the occurrence of flow-limitation.

NEW:

Update (4-10-07):

I have been using a “loaner” CPAP machine from Apria for more than two weeks. The loaner machine is set at “5” as that was “my number” ten years ago. Of course, I had manually upped the pressure on my old machine since 1997. Duhhh. But now Apria cannot change the pressure without a prescription from my doctor I have an appointment for April 26 – two weeks from now. Then a new setting will probably require a sleep study to be justified.

Also, my husband, who has become very intolerant of late, claims that I am now making more and louder snoring noises than I have ever annoyed him with in the past ten years. I am offended and upset with his intolerance as I am doing everything I can to correct the situation, short of buying my own machine, but it will no doubt have to come to that although I haven’t given up yet.

I called Capital Blue Cross again this afternoon as I just cannot understand or accept that Capital Blue Cross insists on the old machine being repaired when the new prescription is for a totally different auto-adjust machine. This does not make sense. A CPAP is NOT an APAP.

Result: It matters not that the prescription is for a different machine that functions differently and has been prescribed by my doctor to better treat my severe sleep apnea, Capital Blue Cross is “playing doctor” and will not pay for a new machine. CBC insists on repairing a machine that is not medically recommended for me at this present date.

I am not sleeping well nor for long enough periods. I am running on 4 ½ hours of sleep as I key in this update. I have also been experiencing fatigue and mild depression as well as headaches when I awaken during the night.

I am “eligible” for a new mask on April 19. With a new mask (I have had difficulty with the one handed me six months ago and which also started this nightmare) and my old machine back set at a better pressure (guessed at by me), maybe I can get by as I have managed to do for the past ten years – no thanks to my health-care providers!


ps: I requested a copy of my ten-year-old sleep study today (to what purpose I really don’t know). The person on the other end of the phone commented, in a pleasant and joking manner, that this was the oldest sleep study she had ever asked to find!

Have you contacted your state licensing bureau and filed a complaint against both CBC and Apria? If I"m understanding you correctly CBC was originally okay w/purchasing a new machine until Apria thru a wrench in the works and now CBC is siding w/Apria. I'd file a complaint against both.

Slinky,I intend to follow through with official complaints -- just waiting for the final outcome.

It was the Captial Blue Cross Customer Service people who misled me. Okay, they lied!

Slinky,

I will be sending letters of complaint to one and all -- just waiting for the final outcome.

It was the Capital Blue Cross Customer Service people who misled me. Okay, they lied!

Q

the problem is with Apria. Here is another option:

Tell your doctor that is has been more than 2 years since your last PSG and have him order up another PSG titration study for you. Now BCBS will have to pay upwards of $3,000 for that study instead of giving you the Autopap to begin with, all because of Apria stupidity.

You would need that titration even with your Old machine repaired. Sometimes you have to hit them where it hurts before they grasp the concept.

In the mean time which machine loaner did they give you? I'd bump that sucker up to about 8cm pressure if it is a straight cpap like a Remstar Plus (Apria only gives you the cheapest thing on the planet).

I agree with Snoredog, have a sleep study. You really need one anyway since it's been 10 years. Especially since you had to guess at what pressure to use when you bumped up your old one. I know they're not fun -- it's been 4 years since mine.

List here what the loaner machine is -- if you need help in bumping the pressure up.

'Tis a REMstar plus.

I have resigned myself to having another sleep study.

Picked up a copy of my 1997 study today -- 49 apneas an hour and up to 27 secs. an episode. Golly that was nearly one a minute! Seems like a lot to me. Guess I do need to know what's happening ten years later.

I did get a snicker out of the ending remarks "She will be followed on a regular basis in the Sleep Laboratory to assess continued efficacy as well as compliance with the apparatus."

Well, if you need to raise the pressure, and if you don't know how, try this (the Remstar Plus and Pro are similar -- this should get you in there).

REMstar Pro 2 Setup

When in the Setup Menu, the humidifier ^ and ramp v buttons operate as up and down keys to change the settings, the left/right user buttons < > allow you to go to the previous/next question or setting, and the pressure start/stop button is used to exit the Setup Menu. Holding the humidifier or ramp buttons down will cause the values to change more quickly.

To enter the Therapy Setup Menu, hold the two top user buttons < > down while plugging in the power cord.
Continue holding the buttons down until the REMstar Pro 2 with C-Flex beeps.

Note: The word "setup" will appear on all of the screens indicating that you are in the Therapy Setup Menu.
If you press the Pressure start/stop button, you will exit the Setup Menu.

a. Compliance hours: (recommend leaving alone) Select next setting with >

b. Therapy mode: (CPAP or CFLE) select with ^ or v Select next setting with >

c. CPAP pressure setting: Select with ^ or v Select next setting with >

d. C-Flex mode (if you chose CFLE mode): Select setting 1, 2 or 3 with ^ Select next setting with >

e: Ramp time setting: Select with ^ or v (ramp time will be turned off with a setting of 0) Select next setting with >

f. Ramp pressure setting: Select with ^ or v Select next setting with >

g. Patient disconnect setting: 1 = on 0 = off Select with ^ or v Select next setting with >

h. Buttons lights setting: 1 = on 0 = off Select with ^ or v (Last setting. Use On/Off button to exit Setup)

UNBELIEVABLE!!! Absolutely unbelievable.

Like the sleep study is a good idea, but given the situation so far it sure doesn't promise much in the way of a decent CPAP machine will be the result.

I hope you have some of their refusals and excuses in writing to include copies of when you send your complaint to the state licensing bureau!!!

Personally I think I'd make sure that the 10 year old CPAP were not repairable.

"I'm sorry as I was unhooking it I spilled the water from the humidifier inside it, then I tripped coming down the stairs and it fell and bounced all the way down the stairs. Did I tell you I live on the 10th floor and the elevator was broke?"

I mean come on that is nuts that they want to try to fix it, I'm sure it will cost more to fix it than replace it, or course that could be the reason they want to repair it, they can charge more.

Good luck getting a new machine.

SleepingBear,

Oh yes, if only I had known before my quest for a new machine what I now know, I would have let the airport luggage handlers have a go at my machine when I was doing a lot of air travel in the past year.

Instead, I carefully carried the thing with me on board where it was safe. Maybe I should schedule a trip as soon as Apria returns my "repaired" unit. Hmmmm. Might not be a bad solution. At the least I would get outta' town! And maybe even get a good laugh if I got to see my packed machine fall off the top of the luggage ramp!

A girl can dream . . .