Insurance coverage and compliance

Just curious, if you aren't using it enough will insurance stop paying for it? If so, how much is often enough?

I've been sick for 3 weeks now with cough, sore throat, sinus pain and pressure and to top that off I had a biopsy on a lesion on my ear that is making it impossible to wear my chin strap as it causes so much pain.

I got a notice from the DME company that I wasn't meeting my goals and to reach out if they can help. I'm currently 4 months into a 10 month required rental period before they will buy it outright.

I've probably only managed 3-4 nights a week for the last couple of weeks. Just not sure if that's enough to make them decide to not cover it.

TIA

No way to answer. Each insurer has different standards; that I am probably pretty sure. I guess the DME is tasked with either seeing that compliance is met or acts as intermediary for the insurance company. I used to be under Humana so I googled for Humana:

-----------quote Does Humana require compliance / adherence for CPAP therapy?

Yes.  Humana requires adherence and will only cover a medically necessary PAP device beyond the first three months of therapy when PAP use is greater than or equal to 4 hours per night on 70% of nights during a consecutive 30 day period during the first three months of therapy.

---------------unquote

Found this info on a 3rd party site as I couldn't find it easily on Humana's website. Your insurance provider may be different. You might also call the DME and ask them as well.

They did mention that I wasn't reaching my goal of 21 out of 30 days which would be 70% so perhaps that's why they have that as my goal. Not sure if they consider the nights I do use it I go far above and beyond 4 hours and usually it's more like 7 1/2 to 9 1/2 hours. If so, my total monthly hours would likely still be enough.

I have to call them to get more supplies so I'll double check.

Thanks.

I just started on Medicare in July so had to switch my DME provider. Medicare requires at least 4 hours of usage 70% of the time or they’ll stop paying for the machine rental. You’ll need to make sure you use it at least the minimum or they’ll stop paying. I have 2 CPAP machines as I have a place in CA and MN and leave one in each so I don’t have to constantly bring it back and forth. I had damage to one on plane trip to CA and had to purchase one myself so I just leave that one there. Since Medicare requires me to use my new machine while it’s being rented, I’ll have to bring the new one with the next few times I travel. Bummer but I don’t want to get stuck with paying for it myself

Good point on the length of compliance monitoring. Most private insurance and Medicare monitor compliance for one year as the machine is a sort of a 12 month rent to own type affair with the insurance company. After that, the machine basically becomes yours. Probably isn't much to be gained by Medicare, an insurance company or even a DME in trying to sell USED PAP machines.