What to do if Your Insurance Company Won't Pay For Replacement CPAP Supplies Because You're Not Compliant.

Quick answer: if your insurance has paused CPAP supply coverage because of documented non-adherence (typically under 4 hours per night on at least 70 percent of nights), the issue is usually fixable. Most plans, including Medicare, allow a new 90-day adherence trial after the underlying problem is addressed. Step 1: identify the cause -- mask leak, pressure intolerance, dry mouth, aerophagia, claustrophobia, or schedule disruption are the most common. Step 2: work with your sleep physician and DME provider to address it -- a different mask, pressure adjustment, added humidification, or switching from CPAP to APAP or BiPAP. Step 3: re-attempt 4-hour / 70-percent adherence over 30 consecutive days. Step 4: schedule a follow-up clinical visit so the physician can document benefit. Most patients regain coverage within 60-90 days of re-qualifying.

This the is second post in a series about the most common reasons why health insurance companies are not covering CPAP supplies. As an equipment provider for many health plans, medical groups and IPAs in Southern California, we're seeing that coverage for replacement CPAP supplies is changing and the process is becoming more difficult. We're sharing our experiences here and hoping to help more patients maximize their health insurance benefits to improve and maintain their health.

Reason #1 is covered in the first post in this series. You can find it here: Why Won't My Insurance Company Pay for the CPAP Supplies I Need?

Reason #2: You're not using your CPAP at least 4 hours a night (aka "non-compliant")

It seems like every month we're learning about a new health plan or medical group that is now requiring proof of compliance before authorizing replacement CPAP supplies. In fact, before our insurance verification specialists can request authorization through some online insurance portals, they need to enter the patient's compliance data. If the patient is not compliant, we cannot even request authorization.

Proof of compliance or CPAP usage typically refers to Medicare guidelines, which defines adherence as using the device more than 4 hours per night for 70% of nights (that’s 21 nights) during a consecutive 30 day period.

Anthem Blue Cross also follows these guidelines. Here's a link to the AIM Specialty Health Polysomnography and Home Sleetp Testing Guidelines that include information about the requirement for compliance which state, "Unless compliance is achieved and documented, the continued use of PAP devices (and the ongoing provision of associated supplies) cannot be considered to be medically necessary."

Until recently, CPAP machines recorded your usage data each morning after you stopped using your CPAP by saving the data in a small memory card inside of your machine. In order to access that data, you would need to mail your data card to your equipment provider for them to download and analyze with software provided by the equipment manufacturer. They would then print out a report and fax a copy to your doctor and your health insurance company.

Thankfully, CPAP manufacturers have responded to tightening compliance requirements by designing new CPAP machines that include wireless modems to transmit usage data to your equipment provider, your doctor and even directly to you insurance company (learn more about that here). We've been dispensing CPAP machines with wireless modems exclusively for the past 18 months. This beats the hassle of mailing data cards back and forth.

Once you've demonstrated compliance for a minimum of 21 nights, your equipment provider can submit the information to your health insurance company to get authorization for CPAP supplies.

What to do if you're not compliant with CPAP therapy and need new supplies:

• Contact your equipment provider and ask to speak to a technician or therapist who can troubleshoot any issues you are having with therapy.Our compliance officer, Linda, talks to patients who are struggling everyday (we've said it before: CPAP isn't easy, but it's necessary!). She makes sure their equipment is working properly, asks if they're having any technical issues and then offers helpful tips for developing the habit of using the device every night. If troubleshooting over the phone isn't enough, we offer face-to-face mask fittings or device check appointments at our local sleep centers. Contact your provider to see what help they can offer.
• Talk to your equipment provider about paying cash for the minimum supplies that will get you through to your next full supply order through insurance. It's a catch-22. You can't get new supplies because you're not compliant, but you can't use your device and become compliant because you don't have new supplies. Unfortunately, the only solution here is to pay cash until you hit the minimum compliance requirements.
• Talk to you doctor.If you've already worked with your equipment provider and you're still struggling with therapy, you may need another sleep study to determine a better CPAP pressure or should talk to a sleep specialist about acclimating to CPAP therapy or even consider CPAP alternatives (learn more about CPAP alternatives here).

While we understand that health insurance companies don't want to pay for equipment that's not being used, becoming successful with CPAP therapy is a challenge. That's why it's important to work closely with your equipment provider and your doctor to get the support you need for sustained CPAP therapy success.

Do you need a replacement mask, filters, tubing or cushions? Check out our new online supply store for purchasing supplies with or without health insurance:

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Sources:

• http://www.resmed.com/us/en/consumer/support/replacement/replacement-option.html
• https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf

Other posts you may find interesting:

• Why Won’t My Insurance Company Pay for the CPAP Supplies I Need?
• Sleep Apnea Patients Must Show PAP Compliance Before Device Purchase or Resupply
• What Are the Side Effects of Using CPAP?
• Best Online CPAP Support Groups and Resources
• “Smart” CPAP Machines for Better Sleep Apnea Treatment
• What Makes the New ResMed AirFit™ 20 CPAP Masks Better?