Newbie Question - Obstacles due to Prescription

[Anasazi]

My sleep lab study was done 3Nov08. I'd gone to my GP MD who ordered an oxygen study that indicated the need for the sleep lab workup. ( I had hoped to attach my Sleep lab summary but I don't see that option on this phpBB ). My GP wrote a prescription in line with what the Physician who reviewed the sleep lab reports indicated.

A work colleague with 5 months positive experience using CPAP has generously provided valuable guidance including sending me to this cpaptalk.com site. With my friend's help, I've concluded that the machine I want is the "M Series Auto CPAP with A-Flex, Heated Humidifier, EncoreViewer and Card Reader". However, the DME that my GP wrote the prescription to says that my prescription will not support the "Auto" features because specific levels are included in the prescription (text = "CPAP at 10cm with 2L bleed in O2 - Report oximetry on above").

I've requested that my prescription be amended by my GP to read "Auto CPAP of Patient's choice at 10cm with 2L bleed in O2 - Report oximetry on above" and sent to the DME, but this has not happened .

I need three kinds of advise from cpaptalk folks as well as any other comments that will help me.

1) Am I justified in pushing for the equipment that I want because I want to understand and work with a doctor regarding titration?

2) Do I need to seek a Sleep specialist MD?

3) Will I be better off using https://www.cpap.com to purchase my equipment and begin working with my insurance coverage myself? I have GEHA, Medicare, and Tricare coverage. Also, I have VA disability coverage but have not been using this because to date I am still employed full time.

Thanks. I look forward to hearing from folks.

[Goofproof]

The least hassle is get what you want from https://www.cpap.com/, it might even be cheaper depending on different INS factors. you have lots of options, you just need to way the costs against the hassles. Your software and reader wouldn't be covered at all. Adding the O2 makes it a little harder, you are still going to have to have a O2 provider, that may make it hard to get away from the DME. Jim

[BeanMeScot]

You can order exactly what you want with the RX you have from CPAP.com. Their prices are much less than the DME. You would have to figure out how much you would pay through insurance. My last insurance was a straight $750 deductible so I used the DME but I had a prescription for exactly the machine I wanted (the same one you want). The O2 makes your case a little different but you can still do the CPAP online and use the DME for the O2.

If you want to handle your own care, you don't necessarily need a sleep doc. I don't have one but I took it upon myself to learn what I needed to know to treat myself. My GP recognizes that and was fine with writing the prescription exactly as I requested. Your case might be more complicated because of the O2 issues, you might find more of a need to have one.

[fuzzy96]

look through the forum. there is a thread for what newbies should do , - very informative . as goof said you have options and should weigh them considering co -pays machine rentals etc.
first get a copy of your original script at least but you should get copies of your study and titrations too
then check to see a machine may be cheaper online and you can use a cpap script to get your auto.

very curious that your script said "report oximetry on above" to my laymans eyes that should entitle you to a pulse oxymeter too. however this wording is not specific and it may be questioned.

a word or two with your GP explaining your situation should get you a script with the wording you need and get them on your side as being a "partner" in your tratment

good luck and welcome aboard

rick

[GumbyCT]

While you certainly should be able to get a "data capable" machine from your DME, they likely will not give up an auto. So I would press them for a data machine.

A good sleep doc is always PLUS.

Meanwhile, I would sign up at the VA, if you are eligible. Employment is NOT a barrier, they will ask for your Insurance provider is all. Provide VA primary doc with a copy of your PSG on your 1st visit and about 1 month later you should get a machine from them. My 1st machine from the VA was an auto M w/cflex. That enabled me to start tracking my therapy myself. The VA has its pros and cons but the machine will not cost you a dime. So the whole process with the VA may take a couple months, unless you gently nudge them along. They also handle Home O2 thru the same dept., Pulmonary.

Good Luck,
GumbyCT

[papdad]

I am currently on supplemental oxygen and xpap therapy with medicare/medicare supplement insurance. Supplemental oxygen it covered 100% by medicare & medicare supplement* --- concentrator, compressor, bottles, tubing, etc. Medicare would not provide an APAP starting out for me and I was provided a CPAP. About one month went back to previous pulmonary doctor, took my test results and explained that I was having a very difficult time with straight CPAP. He said that he could write a letter to my DME changing my prescription due to the fact that I could not tolerate straight CPAP therapy and that medicare would approve the change. DME agreed.
Sometimes we just have to work the system.
Luck, Norm

Edit: *Medicare & medicare supplement pays for supplemental oxygen.

[jnk]

. . . work colleague with 5 months positive experience using CPAP has generously provided valuable guidance including sending me to this cpaptalk.com site.

Now THAT is a good friend! Buy him/her a bottle of whatever he/she drinks.

. . . With my friend's help, I've concluded that the machine I want is the "M Series Auto CPAP with A-Flex, Heated Humidifier, EncoreViewer and Card Reader".

Good choice!

. . . the DME that my GP wrote the prescription to says that my prescription will not support the "Auto" features because specific levels are included in the prescription . . .

Your prescription may need to mention "auto" before your DME will give you one.

. . . I've requested that my prescription be amended by my GP to read "Auto CPAP of Patient's choice at 10cm with 2L bleed in O2 - Report oximetry on above" and sent to the DME, but this has not happened .

Your doc can fax the DME a prescription with the words "patient may use an auto." Some docs hesitate to dictate the use of an auto because they fear insurance won't cover it unless a patient is failing to be compliant for a reason that an auto will solve. Doc's may be afraid to put their patients in the awkward position of being presribed something insurance may not pay for. I don't know if that fear is justified.

. . . 1) Am I justified in pushing for the equipment that I want because I want to understand and work with a doctor regarding titration?

Pleasant pushing should be welcome, if you can explain your reasons in a way that is understood and you give everyone a way to cover themselves for what they do.

2) Do I need to seek a Sleep specialist MD?

That depends on a lot of factors. A sleep doc can pick up on a lot of things a GP is not trained for, especially in understanding the big picture spelled out in a PSG sleep study as explained by a tech. But I'd rather have a really sharp GP than a bad sleep doc. I wouldn't fight with anyone over their personal decision on that. But for me, I'd want a sleep doc to examine me to see if something beyond cpap might be needed in conjunction with the cpap therapy.

[Edited the above to correct a few things I see now I got very wrong, now that I've read Slinky's exerienced words in the post, below.]

[Slinky]

You can get an autoPAP thru cpap.com w/a CPAP prescription. AND you can get your 02 supplementation from the local DME w/that same prescription just advising them you already have an xPAP and which one you have. They might not be happy they lost out on the sale of the autoPAP but that's their problem, you gave them the opportunity to provide one and they blew it.

OR - just tell them, either they provide you w/the autoPAP you want AND the 02 supplementation OR you will buy the autoPAP online and get your 02 from another local supplier (assuming you've called your insurance to ask what local DME suppliers they are contracted w/and you have the option of more than just this one 02 supplier).

Most all insurances contract w/these local suppliers by HCPCS code, not by brand and model, and auto PAPs are HCPCS code e0601 the same as CPAPs.

02 supplementation is NOT cheap!!!! If you have a copay via your insurances, get your 02 from VA!!!! In our area 02 supplementation runs about $235 a month. The DME bills $492.50, Medicare allows $230.19, Medicare pays 80% which is $184.15 and the 20% copay is then $46.04 monthly.

[Snoredog]

Take your existing script, fax or email it over to cpap.com when you place the order for the machine.

You will have to email them to get the lower price anyway, buying from a local brick and mortar DME is the most expensive way you can go.

If you want Aflex, just buy it and don't hassle with all the copay's, they jack the price UP and you pay the copay on that inflated price so you end up paying more.

Once you go on the machine you may not even need the supplemental oxygen unless you have a impaired lung function, that should have been seen during the PSG. CPAP can bring your oxygen levels back up.

Doctors and DME's don't want you to have a Autopap because that means you don't have to go back and see them every few months and they don't make money when you don't show up or rent your equipment from them.

It is your life, your money.

[Slinky]

That "report oximetry on above" is gonna be a stickler. To me that would read: "oximeter w/sensor" as well since there is no xPAP device that reports oximetry (02 levels) except w/an add-on oximeter and sensor such as the Resmed S8 ResLink, Embla oximeter and sensor additions to the Resmed S8 xPAPs. They "might" be able to wiggle their way around that by providing a separate recording oximeter w/sensor - but insurances almost never pay for an oximeter and sensor even if scripted and THEY are EXPENSIVE.

You might need to discuss these problems w/your ordering doctor and maybe change that script to list two pressures, any one or two cms below your titrated pressure and 1-2 cms above your titrated pressure so that there is a pressure range or at least 4, maybe even 5 (the DME could try getting by w/a straight CPAP w/some form of expiration pressure relief if the pressure range is 3 or less) AND "full data reporting capabilities" or "access to Efficacy Data".

I'd recommend the Covidien Sandman Auto, the Resmed S8 II AutoSet as two you would be quite happy with. The Respironics M Series Auto is another you could consider.

If what your doctor intends is that you have 02 supplementation overnight, every night, w/your xPAP, then the order needs to be rewritten ad "add 02 at 2 L/M bled into tubing" or " add 2L/M of 02 supplementation w/xPAP".

[carbonman]

1) Am I justified in pushing for the equipment that I want because I want to understand and work with a doctor regarding titration?

You are justified in pushing for what you want, because
it is your therapy and it is your life.
Become your own best therapist.
Do not let any person or circumstance prevent you
from getting the absolute best therapy you can get.

Thanks. I look forward to hearing from folks.

It's your life.
It's my life.

All the best, it's a journey.

[Anasazi]

I am blown away by all your caring, wise, intelligent, and quick responses. My faith in humanity is restored.

I know now that achieving a working CPAP therapy is not the straightforward mechanical process of "get the equipment and you are all set" that I naively believed initially. Having seen the on-line images of the equipment I have been puzzled about how the oxygen is introduced into the system and if I will have a tank along side my bed. Travel may be difficult if I must take oxygen along. Is having oxygen involved unusual i.e. less than 20% of CPAP cases? Slinky has really fleshed out what I need to get and great wording for a prescription.

On the emotional side - now that I know that I do have sleep apnea, I worry about any long term damage that I may be doing by having low oxygen and if I should rush to therapy. Of course, I do have a sense of urgency in that I am excited with a prospect of improved sleep with the prospect of an improved quality of life.

The "report oximetry on above" that fuzzy96 on my prescription mentioned is a puzzle to me as well. This morning Slinky has explained and clarified the oxygen issues. My interpretation of that is that the Doctor wishes to have a report of the oxygen levels from the DME. I have the uncomfortable feeling that my Doctor has not dealt with sleep apnea patients and is reliant upon the DME that may not really have qualified therapists. [BTW - are there standards and qualifications for DME sleep therapist?]

I am happy to report that I have been taking advantage of the "very informative" threads and features of the Forum noted above. All of this and your kind, informed, and intelligent responses are making this challenge a great deal more palatable.

I think that I was looking and hoping for a quick fix, but I now realized that an informed methodical approach with a lot of help from my friends (you all are among my friends) is best. I am fully covered as a disabled veteran via the VA. I have limited my use of my VA benefits due to stories of delays and sometimes shoddy treatment mentioned by other combat veterans. GumbyCT and Slinky have helped my thoughts on that issue. I hate to postpone getting the therapy started by a few months, but since I now understand that quality equipment is provided by the VA, perhaps the delay is worthwhile.

Thank you all so very much!!! You all have brought my understanding about CPAP that I might never have know or at least may have taken countless years to discover without your help. I look forward to continued participation and contacts from you.

[snoregirl]

One more thought. If you do get your apap via cpap.com without insurance or you try to get reimbursed and can't, if your insurance covers almost all, consider getting insurance to provide you with a good data-capable machine you can use for backup or travel. Only do this if you have a really low or no copay. Simply put, get what you can.

[jules]

Oxygen is provided using one of 3 methods.

1 - A liquid O2 tank is at your house and routinely filled.

2 - Those big green tanks are delivered periodically and they have some smaller ones that provide about 5- 6 hours of 2 l/min flow.

3 - An O2 concentrator which is a big "pump" type machine that filters the O2 in the air to produce a stream that is over 90 % pure O2. This can be a fill system too where the patient fills their own bottles to carry around shopping (you can see people with small backpack size tanks sometimes at the store - those are home fill bottles).

Of these 3 method the most common I understand is the O2 concentrator. A back up small E (refers to size) is also left. You run the machine when you need O2. They can be noisy (I know - been on O2 with and w/o cpap myself but no longer am). They are pretty bulky but have gotten smaller and lighter over time. The smallest portable ones are "pulse" and not suitable for cpap use; you need a continuous flow one.

When you get O2 from a DME, they should be able to fill you in on the travel services they provide (or don't provide). I hauled one cross country on a plane - 28 lbs and got flack at both airports but got it on with me by showing them the script and that I wasn't using it onboard.

A big national company like Lincare or Apria might be a better option (oh, that hurts to say that) if you do a lot of traveling as they are to provide O2 when and where you need it. You need to look at how much traveling you do and use that information as you interview the DME. Your life will change as if you need O2 delivered, you need to key them in where you will be and when etc. My experience with Lincare was service quality varied, but I didn't have a lot of experience. My billing experience with Lincare left much to be desired.

Going back to the cpap, I understand Medicare will not reimburse on a cpap.com purchase. You need to check your insurance and see if they will reimburse for an online vendor.

You have a lot of homework to do. Start making lists of questions for the DME's and your insurance companies.

[Slinky]

My set up is as follows: Medicare provided a 5L oxygen concentrator added to my xPAP therapy at 2L per minute overnight. The attachement is simple enough, a little plastic "tube" w/a "nipple" on it. The attachement is put on the xPAP humidifier w/the mask hose attached to its other end. The 02 tubing is attached to the "nipple" on the attachment.

I've also have 4 "E" tanks (I think they are the larger ones) that have a pressure regulator and provide continuous pressure as emergency backup for the concentrator during an electrical "blackout" plus 8 small "B" tanks w/a pulse regulator (releases 02 on inhalation) w/a nylon carrying case for when I'm out and about shopping or whatever. You probably wouldn't need the smaller tanks for outings. Just the backup "E" tanks to cover during possible electrical outage.

I haven't flown yet since being put on oxygen. My local DME supplier only covers about 2/3 of our state. So when I travel out of state by car they loan me a 3L concentrator. We just sit it in the back seat and strap it in w/a seat belt. And then provide me w/as many "B" tanks as we think I will need. Or they have also just made arrangements w/a local DME supplier at my destination to provide a 5L concentrator and any extra "B" tanks I might need in my town of visitation. So far I've only made 6 hour and 12 hour drives one way out of town.

It might well be though, that your doctor only intended one or two nights of overnight oximetry after you've adjusted to or if you have trouble w/your xPAP. That isn't a problem and can be provided by your local DME supplier including the downloads of the data for those one or two nights or occasional nights (once every 3 months or so). And this your insurance should pay for.