Hi everyone,

I am so mad I can barely type.  It turns out my doctor did request an auto-titrating machine which is fine but I STILL have to have another sleep study done in order for my insurance to cover the costs of the mask, etc.  Right now I have 2 choices according to the supplier of the masks.  One, I can get a mask to use for 2 weeks and pay $100 for it, then STILL have to go for a sleep study (for the 3rd time, 1st time I never feel asleep) to do the titration.  Or, I just go ahead and get another sleep study done and then get fitted with a mask.  I am trying to call the doctor to find out why they did put a mask on.  I don't get it.  The doctor when he called me the other night to tell me I had sleep apnea said that the ins will cover the mask for 2 weeks and then I will have to pay for it.  That was a load of !@#! and he didn't mention anything about another sleep test.  So what do I do?  I really don't want to have another sleep study done incase I don't fall asleep again.  I don't know if they will cover me for a 4th one.  I guess I HAVE to fall asleep in order for me to get a mask covered by ins.  I am so upset about all of this.  The only helpful and understanding person so far has been the lady and the supplier.  And of course, all of you!    I am beginning to think I should find another doctor.  

Any suggestions?

Wendy

Wendy,

Some quick questions to ask the insurance company:

1.  Do they pay for CPAP and APAP machines and if so what percentage.  EVERY insurance company is very different.
2.  Will they cover the second half of the sleep study.  AND, if they do cover it what is to be your portion?  That is a very important question to ask.  I know many people have split nights.  The first being they study you while asleep and then you go back a second time to have the titration done.  Of course mine was different as I had both in the same evening.
3.  Who is the supplier.  

Question to ask the sleep clinic:

Why didn't you do the titration?  Is it your normal practice to do a two-night study?  What happens after the second study?

One thing that is bugging me is why your doctor is mentioning you have to pay for the mask but doesn't say anything about your machine?????  Doesn't your insurance pay the bills first and then you pay your portion afterwards?  How my insurance works is my DME (durable medical equipment supplier) sets me up with my equipment.  AFTER I have found the right mask my DME then bills my insurance company.  After they have been paid by the insurance company I will get a bill from my DME to pay my portion.  In my case, my insurance pays 50% of the machine and masks (IF I go to the supplier they want) after a $250 deductable.

Good luck Wendy and please keep us informed.

Melinda

Folks, there is only one billing code for CPAP and APAP, if billed properly, insurance companies do pay for APAP.  The problem often is that when asked, they see no code for APAP so therefore it is not covered.

You will need to have a titration study done, so I would do it and get it over with.  What it sounds like is your insurance company wants to see that CPAP works for you (treats your apnea) before paying, and the titration study will do that.  

As to the reason.  There are 2 different types of studies.  One is a split night.  This is where half the night is being monitored, the second half is on CPAP if indicated in the first half of the night.  The other is a where the monitor you for the first study, then titrate you the second study.

So what happened is not uncommon.   As to your insurance covering it or not, you will need to talk to them.  But if you do go for another study, I would talk to your doc about getting a sleep aid if you are worried about not being able to fall asleep.

It must be that my ins. co won't pay for the mask AND machine until I have the titration done.  They will cover another study with the mask and machine and they will cover any mask and machines I need so I don't have to pay anything and something about a new mask every 3 months BUT it sounds like I need to have the titration done.  If I use the auto machine from them and pay $100 for the 2 weeks then I still have to go to get the sleep study done again so I just may as well go and do it and get it over and done with and hope I fall asleep.  I have a sleeping tablet that worked last time and I slept for 4 hrs.  

My problem right now is that I called my insurance co.  and they said that cover everything.  However, the DME says otherswise so who is right.  I have a feeling the cust. ser. lady at my ins. co. is wrong but they are calling me back tomorrow.  

I also called the doc to find out WHY they never used a mask on me.  I WAS meant to be a split study because that's what they told me and they showed me a movie on it too.  That's why I presumed I didn't have sleep apnea when I woke up because they never put the mask on me.  THere must be some reason why they never used the mask.

Thinking about it I am going to double check about the machine AND the mask.  I never thought about the cost being different but I was told I wouldn't have to pay anything.  Is it normal to get something in writing?  I just have a bad feeling about all of this.  I would have thought there would have been some sort of payment.  

Wendy

Insurance companies will not give you a letter as they do not know all of the facts until the paper work comes in from the DME and the Doctor.

They answer you with very general guidlines but usually make some sort of statement regarding the final decision. If they don't it is usually a clause in your policy under exceptions or what we will pay title.

Hang in there and just flow with all of the requirements. I have had a CPAP for 12 years. In the begininig I had four studies in 3 months (no tritation).  The doctor just said oh at your weight we will set it at 7 let me know how that works. 11 years later I lost 60 pounds and the insurance company wanted 3 more studies with a tritration this time. My machine is now at 11.5.

By the way I have always been diagnosed with central sleep apnea and Narcolepsy. It was kind of hard to tell if the machine was making a difference until 2 years ago when A medicine came out for Narcolepsy.

I am totaly disabled from it all so it was hard until I just did what they said and went with the flow.

God Bless

Wendy, it sounds like all this is good news to me.  Your insurance will pay for it, and initially you thought they would not.  I know medicare insists on a titration and to me it makes sense before they pick up the cost of a machine.  I would think your insurance company would know what they will pay for, I find it odd that a doctor gets involved in telling you things like that.  Often there are insurance experts in the doctors office that might, but in my experience doctors aren't too good with details like insurance, cost of meds, etc. etc.  

Judy

Judy, it is the DME that is telling me there is a cost not the doctor.  $100 for 2 week, then another sleep study and the ins. will cover it.  However, the ins. co. is saying it all covered but I don't think that they understand I haven't had the titration although I have told them.

Wendy

Wendy,

Just get the titration and be done with it.  That way you can usually try out different masks and the results are interesting.  Even if you get an autopap, it wouldn't take all the measurements that a titration study would.  If the insurance requires it, they will pay for it,no doubt.

Judy

Hi,

Now I am being told by the DME that my ins. co. REQUIRES me to have the titration study donebefore they will cover anything.  However, when I call my ins. co. they said that EVERYTHING (mask, machine, etc.,) is covered just as long as my doctor has diagnosed me with sleep apnea.  So, who do I believe.  To get something in writing from my ins. co. it will take months so they said.  They said that the DME was wrong and that they need to "run it though." (whatever that means).  So I have to wait until Monday to tell the DME that they are wrong.  I just have a bad feeling about all of this.

Wendy

Wendy,

I know you are apprehensive about the titration study, but you really should have it done, especially if it is covered.  You could get by with just getting an auto and relying on it, but the gold standard for determining the effectiveness of treatment is a sleep study.  As to the insurance company, you will get different answers depending on who you talk to (at least I did) and your DME might be giving you the "pat" answer.  But in the meantime you are not getting treated.  Another option is to find a different DME, but if your insurance company does require a titration study, you will be left holding the bag for a lot of charges.

I think I understand your situation.  It should work out very easily, but I do think someone isn't making it clear how things work.  Every insurance company is a little different, but the cpap and gear should be covered.  You may be renting it for a short time, then the insurance will pay for the gear.
It is just a standard way that insurance has chosen to handle this.
I had one sleep study to determine if I had sleep apnea-no mask.  If the apnea was at a certain level of severity they would have put the mask on me that first night to speed up the process of getting me treated.  I did not meet the level of severity so I came back a second night to wear the mask and have my pressure level determined.  They sent me home the next morning with my machine and gear.  I was set on autopap to give the doctor time to read my study and a week later the machine pressure prescription was set.  I paid rental on the machine for about 5 months.  Now actually the insurance company paid part of the rental.  Then the machine became my own.  The insurance company paid their share of the machine at that time also. The 100.00 is probably your share of a rental fee. I think you have to do the tritation because you didnt sleep during your study and although your on the autopap for 2 weeks your insurance company requires the other.  It sounds like you should be ok .