Can anyone out there help. Just got a letter from my insurance denying BIPAP AUTO sv. They stated that this is experimental tratment and would not approve it. My insurance is tri-care prime. I don't know what to do. My doctor requested it, based on my complex apneas. I have gone thru CPAP and BIPAP auto, and did very well with ASV according with my sleep study.

qjosea wrote:Can anyone out there help. Just got a letter from my insurance denying BIPAP AUTO sv. They stated that this is experimental tratment and would not approve it. My insurance is tri-care prime. I don't know what to do. My doctor requested it, based on my complex apneas. I have gone thru CPAP and BIPAP auto, and did very well with ASV according with my sleep study.

You insurance should have an appeal process, ask what it is, then get documentation from your doctor stating why your machine was recommended, why CPAP, BiPAP isn't the suitable treatment, and the medical consequences of improper treatment and burden upon insurance for improper treatment.

elg5cats

Thanks elg5cats I just got the letter from my insurance. I will call my doctor Monday and fax a copy of the letter of denial.

It's curious that they would think it's "experimental" when these devices have to be approved by the FDA before they can be put on the market.
It might also be advantageous to contact Respironics (I assume that's the brand of ASV machine you're referring to) to relay what Tri-Care told you. Maybe they could also provide some "ammunition" for you to get the machine you need.


Den

Respironics has reimbursement suggestions and Medicare guidelines on their site:
http://global.respironics.com/UserGuide ... 043494.pdf

And most insurance companies mirror Medicare guidelines.

Experimental my foot! Look how many people here are using the ASV machines. This is insurance companies either trying to be 'profitable' or socially responsible'. Their money perish with them!

Hit them and hit them hard with your appeals process. Do not take 'no' for an answer!

timbalionguy wrote:Experimental my foot! Look how many people here are using the ASV machines. This is insurance companies either trying to be 'profitable' or socially responsible'. Their money perish with them!

Hit them and hit them hard with your appeals process. Do not take 'no' for an answer!

His insurance if Tri-Care Prime. That's the gubbermunt......the military.....it's run by the Department of Defense (DOD).
Goes to show you how much they care about the folks who have served to keep us safe and free.


Den

This is just the camels nose, wait and see when Obama Care takes over. Then care for use hosers well go the way of the dinosaurs. We will have to justify every piece of equipment that is justly requested by our Dr. This is not good. Now its your turne.

Thanks,

I would ask the doctor what the diagnosis s/he used on the submission.

You have to follow the qualification guidelines exactly or it will be denied.

The Dr. stated complex apnea. The insurance based their decision on that ASV was experimental based on some peer review. I know that ASV is approved by the FDA, so how they can base their decision on some peer review I don't know. By the way, the decision to disapprove was from some nurse not even a Dr. I guess she is escape goat. Well I will file a appeal on Monday, first I need to speak w/my Dr. and see what he can do, or advise me. Thanks for your support.

Re the SV machines being experimental. They were that 9 or so years ago. But as I understand it they are certified therapy machines with full FDA approval and each vendor (Respironics, Resmed & Weinmann) all specify the categories of SDB and modalities, that can be applied.

I'd be inclined to challenge the ins co on their claim the SV machines are experimental. Just gather the brochures from the two US FDA approved brands (Respironics and Resmed web sites) along with the statement that they are FDA approved and ask the ins company for their justification that they are experimental.

The Bipap Auto SV addresses the SDB variants shown in the image just below ...

Taken from this doc ...
http://www.internetage.ws/cpapdata/manuals/bipap-auto-sv-preso.pdf

I am in little doubt there are a few of us here who can produce documents (or links to) showing these machines were being trialled back in 2001 (admittedly under different names). I know I have posted some of them here at cpaptalk in the past.

BOTTOM LINE here is that the two main SV machines depicted here, may have been experimental 8 years ago but today are FDA approved SDB therapy machines. This fact is irrefutable.

Good luck DSM



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More SV trivia ...

By 2001 Resmed had developed this SV machine below (Sullivan Autoset CS) that became today's Vpap Adapt SV


In this link Resmed (2001) acknowledge they are trialling the machine & seeking FDA approval, later granted ...
http://www.talkaboutsleep.com/sleep-disorders/archives/Snoring_apnea_resmedautoset.htm

I believe the patent (linked to below) was applied for on May 21st 1999
http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO2&Sect2=HITOFF&p=1&u=%2Fnetahtml%2FPTO%2Fsearch-bool.html&r=7&f=G&l=50&co1=AND&d=PTXT&s1=6,532,959&OS=6,532,959&RS=6,532,959


Also in about 2001 Respironics had also developed their SV machine called the 'HeartPap'. This machine is todays Bipap Auto SV.


I think this is the Respironics patent for the HeatPap (click the 'READ THIS PATENT' button) ...
http://www.google.com/patents/about?id=U40QAAAAEBAJ

*******************************************************************************************************************************************

Just to prove the point that the Heartpap is the Bipap Adapt SV, see the below Respironics brochures from the past (the 1st is from a Japanese brochure & the later from a US brochure ...

Prevailing in a case like this requires attention to every detail and countering their basis for denial point by point. Sometimes insurances routinely deny claims at any little excuse (or none) in hopes that either the patient won't appeal, or they'll at least be able to hold on to their money a bit longer. But even with an ethical insurance company, there has to be protocol to minimize waste, and they need proper justification to approve a claim. It yanks my chain when an insurance company presumes to know more than the doctor what is best for a patient, like in your case where you have already gone thru the other options. Find out what they need to hear, and give it to them the way they need to hear it. An appeal can be wasted by haste and incomplete presentation. And never underestimate the value of speaking with a supervisor. Being able to access one in the department that approves the claims could be an added bonus (but good luck with that). Having someone know that what you give them will be per their instructions could chip away at the disconnectedness of the whole denial process. A cover letter with the appeal stating "per instructions of Ms. So-and-So" couldn't hurt.

My young adult daughter was denied medical coverage due to a preexisting condition, a blood disorder. At first she was flat out denied coverage. Then they said she could get coverage but she had to sign a waiver that nothing related to this disorder would be covered. I knew how that would turn out - every little thing they would try to relate to her disorder and would be a fight. I got busy and sent her links to studies from esteemed medical facilities showing that her disorder is considered an incidental finding and bore no impact on her future health risks. In the end she got full approval, but the burden of proof was on her.

All the junping thru hoops shouldn't matter. A claim is a claim, right? But if you see your insurance company is quick to deny without apparent justification, then extra measures can't hurt. Leave them without excuse.

Best wishes in this.

Kathy

Thank you for the info. I did some research on my own, based on the paragraph Tri-care used to disapprove. Tri-care policy manual Chap. 1, Sec. 2.1 - unproven drugs, devices, treatments, or procedures. I went to the FDA web site and found devices cleared: Feb. 07 510(k) approved
Resperonics , BIPAP ASV , 510(K) NO. K063533, Attn: Zita A. Yurko, SE decision made 20 Feb 2007, 510(k) summary available from FDA. I hope this information and any letter I get form my Dr. Will help me clear this hurdle.

qjosea wrote:Thank you for the info. I did some research on my own, based on the paragraph Tri-care used to disapprove. Tri-care policy manual Chap. 1, Sec. 2.1 - unproven drugs, devices, treatments, or procedures. I went to the FDA web site and found devices cleared: Feb. 07 510(k) approved
Resperonics , BIPAP ASV , 510(K) NO. K063533, Attn: Zita A. Yurko, SE decision made 20 Feb 2007, 510(k) summary available from FDA. I hope this information and any letter I get form my Dr. Will help me clear this hurdle.

You are a champion, I am sure you have just gathered the proof you need. Perhaps a 'polite' "I think the status of the Bipap Auto SV has changed recently and you may not have been aware" will give them a face-saving way out.

It is terrific to see the results of people doing their own research & I hope your efforts get well rewarded

Again, great going !

DSM