Hi again lauriefeenstra:

My husband has a MedicareAdvantage plan--but he also receives care from the VA. He has watched a ga-zillion YouTubes about health insurance. (He finds them interesting).

He told me some things this morning.

First, it is better to have an Advantage plan PPO than an HMO, because the network is broader (although cost is a bit higher for PPO plans). This is something you can't change once your insurance is established, unfortunately.

In my opinion, it also may matter how the doctor writes the order (prescription) for the device... Not all doctors are familiar with the right terminology and what to include, but I understand you need to use a doctor within your network with an Advantage plan.

If you have a PPO, you have a better chance (in my opinion) of actually seeing a doctor who is a RLS specialist (not just asking your family doctor to write the order).

My husband says the success "on appeal" rate with MedicareAdvantage plans is very high. They deny without basis and hope people give up after the first round. This is an established fact. You aren't that only one who has been told crazy BS ("it's experimental") by an Advantage plan. It's common.

My husband doesn't want me to quote the success rate of appeals to you because he can't remember exactly--but the first thing he said was about 78%. (So --darn them--you appeal this!)

This is something I can add. The Nidra is FDA approved and Medicare (not an Advantage Plan--Medicare itself) pays for mine. Medicare won't pay for "experimental." Of course, it isn't "experimental." There has been a lot of published research (how I found out about it) and there is still research going on (I've been participating in a study for the past year) but it is already FDA approved (not a slip-shod process--an ordeal for the company).

I do not own mine. Medicare is "renting" them for me. Medicare also pays for the sticky-pads that are supposed to changed weekly. I meet the deductible, in general, for any and all health care I receive, and then Medicare pays the rest--including all the Nidra costs.

A Nidra (I asked when I got mine activated) costs $6,000 or $7,000. Is it "worth" that? Medical equipment is meant to be paid for by insurance, not out-of-pocket. Costs reflect the costs of research and development. It is well-designed, but that much money ??? And, even if you wanted to buy one, it still would need to be prescribed by a doctor. However, insurance should cover it---that is why we all have health insurance.

When I got mine (a year ago this month) the company (Noctrix) warned me that many insurance claims were being denied--extending the time it took to get Nidra.

My expert RLS doctor wrote the order, including what he thought was relevant, and I got Nidra about 3 weeks later. I've never asked my doctor WHAT he wrote, but I assume he went through the list of everything (medication-wise) that had been tried with dates etc. In general, I believe insurance wants all the hoops to be jumped through before approving something more expensive. However, since I never took any dopamine agonist drugs, that wasn't a requirement. I had been through the "gabas" and I had IV iron and I had been to 2 sleep psychologists.

Not that your plan is actually being stymied by how the prescription was written--my husband says Advantage plans are notorious for denying health services and expenses, just how they do business. Most people give up. (But, not you, friendlaurie!!!)

I understand you can't choose an out-of-network doctor to prescribe the Nidra, but you want the doctor to write the prescription in the best way (AdvantagePlan, or not). Logically, I think that would help in an appeal.

By the time I could get a Nidra, I had already called the Noctrix people--talked to a very nice nurse--and she was informative and helpful. That's where I heard about the insurance denials for Nidra. The company told me.

I suggest you call Noctrix (google their phone #) and find out if other AdvantagePlans have been funding Nidra rentals. My impression of the Noctrix company and the people who they have hired is very positive. Like they actually understand it's more than just a money-maker for the company--Nidra actually helps people (who are truly suffering.)

They may have some information on how to appeal successfully, what information to include--how to go about it. They can tell you if other Advantage plans have approved Nidra costs.

I'm not sure, but it might be your doctor who needs to make the appeal--not you. If that is the case, it would still be helpful if YOU learned how to successfully appeal (by talking to Noctrix) so you could steer the doctor. Doctors don't like extra work, but they can do something if the "leg-work" of figuring it out has already been done.

I am an enthusiastic Nidra user because it has helped me. I like the company because my experience with their employees has been so positive.

In my opinion, you are wasting your breath trying to "talk" to your MedicareAdvantage representative. Their job is to deny you service. They aren't listening to you. The only thing they will respond to is a formal appeal.

I read a few weeks ago that some MedicareAdvantage companies recently pulled out of New Hampshire completely, leaving former customers high and dry, without health insurance. In general, the Advantage plans started by sucking in customers with all these benefits. Now, benefits are being decreased.

Advantage Plan customers are seniors, who no longer have health coverage through employment and who are likely to need some health care. The idea that they pray on the elderly is despicable.

You seem like a smart person--you ask good questions. Appeal and let us know what happens. Let us know what Noctrix says. Let us know if your need the doctor to be the one making the appeal.

Appeals take time. Even if successful, this will not be immediate. So, you need to get started figuring out how to appeal the denial.

I am pulling for you!