How to figure out if Aetna will pay for my CPAP

I have been diagnosed with OSA since 2007. I was not using my machine since I couldn't stand it (I was in my 30's I thought I was invincible) But now I feel the pain in my chest in the morning getting worse so I decided to get a CPAP machine (my doc recommended ResMed S9 AutoSet) . I tried to go to the original DME (but with a different insurance carrier) who insisted I get a Sleep study done before getting a new machine since I had changed carriers, which I did. Now this sleep study came up with Mild Sleep Apnea diagnosis. Here's part of my report

The patient estimated a total sleep time of 449.5 minutes. Respiratory Analysis demonstrated 60 obstructive apneas and 26 hypopneas, with an APNEA HYPOPNEA INDEX (AHI) of 11.5. The lowest oxygen saturation was 82 %, and 0.8 % of the sleep time was spent at saturations below 90 %. The PLM Index was 2.0 events per hour.

Now Aetna's clinical bulletin states the following

Treatment of snoring alone, without significant OSA, is not considered medically necessary.

Continuous Positive Airway Pressure (CPAP)

It is expected that members receive lifestyle advice where applicable (i.e., helping people to lose weight, stop smoking and/or decrease alcohol consumption).

Aetna considers CPAP or autoPAP medically necessary DME for members with a positive facility-based NPSG*, or with a positive home sleep test* including Type II, III, IV(A) or Watch-PAT devices, as defined by either of the following criteria:
Member's apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to 15 events/hour with a minimum of 30 events; or

AHI or RDI greater than or equal to 5 and less than 15 events/hour with a minimum of 10 events and at least one of the following is met:
Documented history of stroke; or
Documented hypertension (systolic blood pressure greater than 140 mm Hg and/or diastolic blood pressure greater than 90 mm Hg); or
Documented ischemic heart disease; or
Documented symptoms of impaired cognition, mood disorders, or insomnia; or
Excessive daytime sleepiness (documented by either Epworth greater than 10 (see appendix)); or
Greater than 20 episodes of oxygen desaturation (i.e., oxygen saturation of less than 85 %) during a full night sleep study, or any one episode of oxygen desaturation (i.e., oxygen saturation of less than 70 %).

*The sleep study is based on a minimum of 2 hours of continuous recorded sleep or shorter periods of continuous recorded sleep if the total number of recorded events during that shorter period is at least the number of events that would have been required in a 2-hour period. If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that would have been required in a 2-hour period (i.e., must reach more than 30 events without symptoms or more than 10 events with symptoms). Projections of AHI or RDI based upon shorter testing times and/or fewer events are not acceptable for use in determining whether the member meets medical necessity criteria. In addition, estimates of AHI or RDI should include all stages of sleep. Estimates of AHI or RDI that only count events during periods of REM sleep (and exclude periods of non-REM sleep from the calculation) are not acceptable for use in determining whether the member meets medical necessity criteria.

Notes: 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 % reduction in thoraco-abdominal movement or airflow as compared to baseline, and with at least a 4 % oxygen desaturation.

The apnea-hypopnea index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. Sleep time can only be measured in a Type I (facility-based polysomnogram) or Type II sleep study. Thus the AHI is reported only in Tyipe I or Type II sleep studies.

The respiratory disturbance index (RDI) is equal to the episodes of apnea and hypopnea per hour of recording without the use of a positive airway pressure device. The RDI is reported in Type III, Type IV, and other home sleep studies.

Leg movement, snoring, respiratory effort related arousals (RERAs), and other sleep disturbances that may be included by some polysomnographic facilities are not considered to meet the AHI and/or RDI definition in this policy. Although AHI and RDI have been used interchangeably, some facilities use the term RDI to describe a calculation that includes these other sleep disturbances. Requests for positive airway pressure devices will be considered not medically necessary if based upon an index that does not score apneas and hypopneas separately from other sleep disturbance events. Only persons with an AHI and/or RDI, as defined in this policy that meets medical necessity criteria may qualify for a positive airway pressure device.

Aetna considers CPAP experimental and investigational for the treatment of persons with upper airway resistance syndrome (UARS) or for the improvement of seizure control in persons with epilepsy.

BiPAP without a backup rate feature, DPAP, and VPAP are considered medically necessary DME for members who are intolerant to CPAP or AutoPAP, or for whom CPAP or AutoPAP is ineffective. Ineffective is defined as documented failure to meet therapeutic goals using CPAP or AutoPAP during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings). The records must document that both of the following medical necessity criteria are met:
An appropriate interface for the CPAP and AutoPAP has been properly fit and the member is using it without difficulty; and
The current pressure setting of the CPAP or AutoPAP prevents the member from tolerating the therapy and lower pressure settings of the CPAP or AutoPAP were tried but failed to:

Adequately control the symptoms of OSA; or
Improve sleep quality; or
Reduce the AHI/RDI to acceptable levels.

These alternatives to CPAP may also be considered medically necessary for OSA members with concomitant breathing disorders, which include restrictive thoracic disorders, COPD, and nocturnal hypoventilation. An oral pressure appliance (OPAP) is considered medically necessary DME only on an exception basis for members who are unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain, or claustrophobia from masks. A BiPAP device with a backup rate feature (e.g., adaptive servoventilation, VPAP Adapt SV) is considered experimental and investigational for obstructive sleep apnea (see CPB 0452 - Noninvasive Positive Pressure Ventilation).

Replacement of positive airway pressure devices is considered medically necessary at the end of their 5-year reasonable useful lifetime (RUL). Replacement of these items is considered medically necessary prior to the end of the 5-year RUL due to a change in the member’s condition. Replacement needed due to misuse or abuse are not covered.

Based on this they looks like Aetna may not cover the cost of the machine. Is there a way I can find out for sure before going to a DME and having them bill Aetna? If they don't pay I'm on the hook for the DME's ridiculous pricing but if they do cover it I can get the machine at 20% of the negotiated price since I have met my deductible for the year. Any advice?

Call Aetna & ask if you can receive a determination from them prior to proceeding. Usually a DME can & most do, request prior approval from insurance to protect themselves. I would want to talk to Aetna myself if I were you, ultimately you will be held responsible for anything insurance doesn't cover.

If Aetna isn't going to pay, you would be better off buying online, either from our hosts, cpap.com or perhaps used from secondwind.com.

With an AHI in that range, you "need" a co-morbidity for coverage.
If your doctor's diagnosis includes one of the conditions listed, you are LIKELY in like flint.
Your chest pains need to be documented by the doctor--ASAP--
-it may need treatment separate from cpap, you need to make it so.

We have Aetna, I have mild apnea (AHI 13.4) and my O2 only went to 86%. AETNA approved my machine and is just waiting for me to be compliant for the set amount of days before they pay out on the unit. It took about a week for the DME to receive approval. I do have documented mild hypertension and mood disorder so maybe that's why.

If depriving you of treatment puts your health or life in any danger,
it is in the insurance company's best interests to avoid the liability.
Lawyers are drooling.

Thanks for the responses guys. I'll push Aetna for a pre-determination. And push my doctor to send out a really strong letter of medical necessity.

If the Doc prescribes APAP (which you say he did) for OSA (which begins at AHI 5 which you have) then likely Aetna will pay.

I have Aetna and called them on a matter where PROBABLY were not contractually obligated. I had a new mask that would not work and asked when I could get a new one. After a few internal discussions, the rep came on the line and told me, "Buy another mask, we'll pay."

YMMV, but my point is that merely by calling Aetna, they offered to do the right thing.

You have "AHI 11.5. The lowest oxygen saturation was 82 %," which meets the diagnostic criteria and the doc wrote the Rx so I would bet that Aetna will be good to go.

Also, you can have the DME ask Aetna but you are probably better off asking Aetna first yourself.