Auto Pap - Medical Necessity

[darthlucy]

Hi all,

I've read tons of posts about convincing DMEs and docs to give you an apap, but how do you all go about convincing your insurance company? In my case, the insurance will not cover the apap unless it is "medically necessary." I assume this means my doctor would have to send them a letter convincing them of the medical necessity, but does anyone have any magic words that I should ask the doctor to include?

I'm not really having any problems per se, but I'm not convinced I'm at the right pressure. Like many others, I didn't sleep well during my sleep study. The tech even told me the next morning, after titration, that I had slept with my mouth open. I'm skeptical that they could have gotten a proper titration if I was mouth breathing and they didn't switch me to a full face mask. I'm feeling way better than pre-cpap, and my numbers have been good (AHI generally less than 2), but I can't help but wonder if I could be doing even better at a different pressure.

Any words of wisdom? Thanks!

[Wulfman]

With the data-capable Elite, you should be able to monitor some adjustments to your therapy.....you don't REALLY need an Auto to fine tune it. If you move the pressure up or down, the results should be obvious from the data.
You're not NEW to this therapy, so you know about mouth-leaking and all of the things that can affect those adjustments.

Den

[Sleepy Dog Lover]

It is more likely your DME and not your insurance company who has a problem. Insurance has 1 billing code for CPAP and 1 billing code for biPap. Because of this, DME's will try to give you the cheapest machine they possible can. Is it the DME who says that the insurance company won't approve it?

[darthlucy]

I haven't tried the DME yet. My thinking is that if I have the insurance approval first, it will strengthen my case with the DME. I know my doctor (primary, not sleep, whom I've never met) will help me out and pretty much say whatever I tell her she needs to put in the letter. She's a really great advocate for me taking control of my own health.

Den, you're right that I know enough to adjust the therapy myself, and if I can't get an apap, I'll probably go the route of getting the card reader and software to go with my S8. I've been losing some weight and plan to lose more, so I see this as a potentially evolving situation with changing pressure needs, so the more information I have at my disposal the better. I think the apap would allow me to make adjustments sooner than small changes once a week over several weeks until I get it right.

[lifeartist59]

This was how I brought up apap with my physician, and the insurance was fine with it. I said I was told that every 10-15 pound would require a new test, and my test cost 4K so it only made financial sense to get an apap. Good luck!

[darthlucy]

Great idea, lifeartist. Thanks!