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

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:

Other posts you may find interesting:

Comments

  1. Jay Levorson Reply

    If my insurance won’t pay for replacement supplies, them Advanced Sleep Medicine should notify the patient BEFORE sending new supplies and billing the patient for the new supplies. Because that’s the boat I’m in.
    I don’t want $160 worth of tiny paper and plastic swatches for a machine I’m on the fence about using. Thanks.

  2. Gerald J Zito Reply

    My girlfriend had a CPAP that was taken away from her because of lack of compliance. She has COPD and could not breathe with it on. Insurance won’t pay and the company is threatening collection for $2000. I believe she is being punished because she has COPD. What can be done?

  3. Retha Pauline Broyles Reply

    I desperately need a c pap machine as my oxygen level is usually very low. I had surgery and the nurse Asked me if I was on a c pap machine because I sure need to be.
    During surgery, and had l close to 20, my level drops way low.
    Because I have RLS IN BOTH LEGS AS SOON AS ILAY DOWN OR SIT DOWN
    SO I’VE TRIED TWICE AND CAN’T WALK THE FLOORS CARRYING THIS. I’VE TRIED TO SNEAK IN AN HOUR TO MAKE UP WHAT I NEED BUT I CAN’T.
    SHOULD BE SIMPLE TO DO I’VE HEARD, IF I WANT TO DO IT BAD ENOUGH.
    I DO NEED MY OXYGE N TO BRCORRECTLY.
    MY INSURANCE WONT COVER IT SO I’VE GONE WITHOUT ANY TREATMEAT FOR SEVERAL YEARS.
    I DON’T KNOW WHAT TO DO.
    I AM SHORT OF BREATH
    BUT CAN’T DO ANYTHING ABOUT IT. IN WICHITA KS, THE PLACE THAT USUALLY SELLS THEM, VERY HIGH. HAS NONE TO SELL.
    I WANT TO TRY ONE MORE TIME. IT IS NOT MY FAULT IT IS NOT WORKING BUT MY DOCTOR HAS INCREASED MY RLS MEDICATION AND ALSO HAVE HAD BOTOX TREATMENT IN FOR MY BLADDER
    BECAUSE THAT KEEPS ME UP OFTEN. PLEASE HELP ME. No one asks me why I am having trouble. They just take it away from me like im being a child and doing something wrong.
    I can’t vol on

    I can not go om like I have had m
    Had Fuj

    Todo.

    • Jen Atkins Reply

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  4. POLLY BROYLES Reply

    Sorry. For my mistakes.
    It’s late and I’m exhausted.

  5. Alma Valdez Reply

    I use a cpap machine that is now on recall. I* cant use it now and they don’t know when I can get a replacement. My problem also is I got it when I was on Medi-cal and I don’t have that anymore or insurance. I am so exhausted I need a machine but can’t afford it. I get up 5 to 10 times a night and mostly can’t sleep. Please help me with some advice.

  6. subway surfers Reply

    very good and useful article, i really learned a lot of useful information from this article, hope you can share more good articles like this, thank you so much

  7. Anonymous Reply

    I am in the same boat the CPAP company brought me a new CPAP machine and I am on oxygen this was in April of 2021 then in oct 2021 they sent me over 600.00 dollars or CPAP replacements then a week later said they coming to pick up my machine cause I wasn’t in compliment I said I will pay for it they told me no I said well I am not giving it to you I need it we went back and forth to the point it was their fault for assuming my situation and if I can’t pay out of pocket then I don’t know what to tell them then in April of 2022 they sent me my tubbing and other stuff to my oxygen machine and then called me back and said they coming to take it cause I haven’t seen my pulmonary doctor I said what ever I am not arguing with you any more come and take it so it’s been two months since I have had my oxygen and my breathing is getting so bad my oxygen drops to 70 and my heart rate is 130 just walking to the bathroom or to the car and I have a walker I don’t know what to do any more

  8. tcswebmail Reply

    If you are not compliant with your CPAP machine, and your insurance company won’t pay for replacement supplies, you can look into the following options:

    – You can buy a new machine on your own.

    – You can find a store that will accept the return of your old CPAP machine in exchange for a new one.

    – Find out if there’s an organization that offers low-cost CPAP machines.

    – See if there is a way to get supplies from other sources (such as online).

  9. upsers Reply

    If your insurance company won’t pay for replacement CPAP supplies because you’re not compliant, here are some tips on how to get them to reimburse you.

    First of all, talk to your doctor or health care provider about the issue and find out what they recommend. They may be able to help you find a solution that will work for both parties. If they can’t, it’s time to call up your insurance company and see what they have to say about the issue. Getting their perspective may be helpful in finding a solution that works for everyone involved.

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