Recently Diagnosed with OSA

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
JJenkins2005
Posts: 12
Joined: Wed Sep 02, 2015 1:20 pm

Recently Diagnosed with OSA

Post by JJenkins2005 » Wed Sep 02, 2015 2:24 pm

First, I want to all of you for your post...It has really shined some like on what OSA is and how it can slowly kill you.
I think (hope) it has prepared me for this Journey.

So here it goes

After the 5 month wait between the time my Dr ordered my initial study, ordering a Tri Sleep Study and completing the study ... I finally received a phone call with my results stating that I had mild OSA and needed to get a CPAP. The nurse started by saying she was sending my RX and Sleep Study to their DME... I stopped her and informed her that I wanted to get my RX and Copy of sleep study and choose my own provider. Here is a little details about my insurance

Premera BCBS
Plan Type: Shared Deductible
Family Deductible: 2000 - Met
OOP MAX 4000: $3,456 to date.
Insurance pays 90% until OOP Max is met. 100% after that point

Snip from my insurance on CPAP Devices:

First Time Positive Airway Pressure (PAP) Device User
A continuous positive airway pressure (CPAP) device may be considered medically necessary for adult or pediatric patients* diagnosed with obstructive sleep apnea (OSA) when the following criteria are met:


 A physician with training in sleep disorders evaluated the patient and ordered the CPAP device and
 Prior to purchase there is documentation of adherence** to a 3-months (12 weeks) trial of rented PAP
device use.
A bi-level positive airway pressure (BiPAP/BPAP) or auto-adjusting PAP (APAP) device may be considered
medically necessary for patients diagnosed with OSA when the following criteria are met:
 The trial of CPAP was ineffective in resolving OSA symptoms (see Definition of Terms) and
 A physician with training in sleep disorders evaluated the patient and ordered the BiPAP device and
 Prior to purchase there is documentation of adherence** to a 3-months (12 weeks) trial of rented BiPAP
device use.
*NOTE: Children’s symptoms of OSA may differ from adults’ symptoms of OSA. Children frequently exhibit behavioral problems or hyperactivity rather than daytime sleepiness. Usually an adenotonosillectomy surgery is the first-line treatment for OSA in children. CPAP is an option for those children who are not surgery candidates or who have an inadequate response to surgery.
** Adherence to therapy means:
 The patient used the PAP device 4 or more hours on 70% of nights in any 30 day period during the first 3- months (12 weeks) of use.
o A claim submitted with the KX modifier is considered documentation of adherence. (See Documentation section in Policy Guidelines and Coding section)
PAP Accessories and Supplies
Accessories and supplies may be considered medically necessary when used with a PAP device eligible for coverage benefits.

____________________________________________


So I found a DME that was close to my house and I called them up and told them based on what I understood from my insurance and what I read here that I wanted a Resmed Airsense 10 CPAP Elite - Printed off this page (http://www.cpapxchange.com/airsense-10- ... esmed.html)
Heated Hose
AIrfit P10 Mask

They tried to tell me they needed to get PreAuth... Showed them the printed policy that it wasn't required for an E0601 machine... They tried to tell me that it required a 10 month rental.. Told them, I only have to rent for three months before my insurance pays... They said they needed to look into it.

I said ok since my insurance provider is out of WSH State and I live in South Carolina.....


Below is what my RX Reads:

Machine: DME Preference
pressure 6cmH2O
Ramp: Patient Pref
Exhalation Pressure: Patient Pref
Heated Humidifier: Yes
Sig: During Sleep
Modem: Yes



So today they call me and tell me that my machine was in and to come in tomorrow and that all I needed to pay was 75 bucks (Machine, filters, hose, mask, headgear and a chinstrap).. The guy who called me was the Resp Therapist and didn't know any of the details about the insurance but said the lady who handles the billing will be there in the AM when I go....

I called my insurance provider to find out about what I should be expected to pay and all they could tell me was that since it had to be billed through my local BCBS only they knew the contracted rate but of course they won't talk to me since they are not my plan provider....

I know 75 bucks is a little money but I want to make sure that they are not ripping me off or trying to include additional money because I didn't want the machines they had in stock

If there is any more information that I can provide.. Please let me know.

yaconsult
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Re: Recently Diagnosed with OSA

Post by yaconsult » Wed Sep 02, 2015 3:14 pm

You don't want the Elite - it's the low-end model. The insurance pays the same price to the DME, no matter which model of cpap machine he gives you. You should get either the autoset or, even better, the autoset for her.

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Julie
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Re: Recently Diagnosed with OSA

Post by Julie » Wed Sep 02, 2015 3:28 pm

Yes - get an Apap - it will allow you to use 'only' Cpap mode if that suits you, but also lets you use auto mode, which many more people like because it can tell you more about how well you're sleeping if you download the free software from the forum when you get your machine. And as far as insce. goes, the billing codes for Cpap and Apap are the same as far as I know... so that's not a good argument for you to have only a Cpap - make sure your MD writes a new script for one (and not an 'Elite' model but a newer one).

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englandsf
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Re: Recently Diagnosed with OSA

Post by englandsf » Wed Sep 02, 2015 3:41 pm

I would push for a lab titration with your insurance situation right now - and, as mentioned, get "data capable" or Autoset specified on your Rx too.

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JJenkins2005
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Joined: Wed Sep 02, 2015 1:20 pm

Re: Recently Diagnosed with OSA

Post by JJenkins2005 » Wed Sep 02, 2015 3:48 pm

yaconsult wrote:You don't want the Elite - it's the low-end model. The insurance pays the same price to the DME, no matter which model of cpap machine he gives you. You should get either the autoset or, even better, the autoset for her.
My insurance said they will only pay for a APAP if it is proven that the CPAP is not successful.

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Pugsy
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Re: Recently Diagnosed with OSA

Post by Pugsy » Wed Sep 02, 2015 3:52 pm

Just a tiny point of clarification...I don't consider the Elite to be "low end" as it is still a full efficacy data machine...what I consider "low end" are the bricks with no efficacy data or those half assed bricks that just give AHI and that's it.

So the Elite is a full data machine just like the AutoSet is. What the Elite lacks is the auto adjusting pressure (apap) mode....and yes, if at all possible get the AutoSet because we never know just when that auto adjusting (apap) mode might come in handy.

Machines to avoid in the ResMed model line..
S9 machines...anything with the word "Escape" in the model line name.
AirSense 10 machines....the one to avoid is AirSense 10 CPAP as it is what I call the half assed brick. Gives AHI but nothing else..no leak..no event category breakdown...nothing but a single AHI number and hours of use.

Edit...I see that you have already had the cpap vs apap discussion with your insurance company (I am assuming you talked with the ins co and this information isn't coming from the DME because DMEs sometimes don't tell the whole truth)...
while apap is nice to have it isn't the end of the world if you don't have apap mode available.
Some people actually do better in cpap mode anyway. Not everyone needs or wants or even likes apap mode.

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JJenkins2005
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Joined: Wed Sep 02, 2015 1:20 pm

Re: Recently Diagnosed with OSA

Post by JJenkins2005 » Wed Sep 02, 2015 4:02 pm

Julie wrote:Yes - get an Apap - it will allow you to use 'only' Cpap mode if that suits you, but also lets you use auto mode, which many more people like because it can tell you more about how well you're sleeping if you download the free software from the forum when you get your machine. And as far as insce. goes, the billing codes for Cpap and Apap are the same as far as I know... so that's not a good argument for you to have only a Cpap - make sure your MD writes a new script for one (and not an 'Elite' model but a newer one).

The machine has already been ordered..but I will see for sure tomorrow when I get there what was order... My insurance is very strict about paying for an APAP based on what I was able to gather.


A bi-level positive airway pressure (BiPAP/BPAP) or auto-adjusting PAP (APAP) device may be considered
medically necessary for patients diagnosed with OSA when the following criteria are met:
 The trial of CPAP was ineffective in resolving OSA symptoms (see Definition of Terms) and
 A physician with training in sleep disorders evaluated the patient and ordered the BiPAP device and
 Prior to purchase there is documentation of adherence** to a 3-months (12 weeks) trial of rented BiPAP
device use.


I'm going to see what I get from the DME tomorrow but if I can't get them to reorder... I thought the elite was at least the full data capable A10 device.... If I can figure out how to get the autoset instead is this the one I should be getting... http://www.cpapxchange.com/airsense-10- ... esmed.html

JJenkins2005
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Joined: Wed Sep 02, 2015 1:20 pm

Re: Recently Diagnosed with OSA

Post by JJenkins2005 » Wed Sep 02, 2015 4:04 pm

Pugsy wrote:
Edit...I see that you have already had the cpap vs apap discussion with your insurance company (I am assuming you talked with the ins co and this information isn't coming from the DME because DMEs sometimes don't tell the whole truth)...
while apap is nice to have it isn't the end of the world if you don't have apap mode available.
Some people actually do better in cpap mode anyway. Not everyone needs or wants or even likes apap mode.

Yes, I treat the DME like the read headed step child lol... I called and ask my insurance provider and they pointed me to their medical policy.

A bi-level positive airway pressure (BiPAP/BPAP) or auto-adjusting PAP (APAP) device may be considered
medically necessary for patients diagnosed with OSA when the following criteria are met:
 The trial of CPAP was ineffective in resolving OSA symptoms (see Definition of Terms) and
 A physician with training in sleep disorders evaluated the patient and ordered the BiPAP device and
 Prior to purchase there is documentation of adherence** to a 3-months (12 weeks) trial of rented BiPAP
device use.

JJenkins2005
Posts: 12
Joined: Wed Sep 02, 2015 1:20 pm

Re: Recently Diagnosed with OSA

Post by JJenkins2005 » Wed Sep 02, 2015 4:06 pm

englandsf wrote:I would push for a lab titration with your insurance situation right now - and, as mentioned, get "data capable" or Autoset specified on your Rx too.
I had a lab study for both.. That's why it took sooooo long for everything to happen... The sleep lap is running 6-8 weeks wait on studies.

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Pugsy
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Re: Recently Diagnosed with OSA

Post by Pugsy » Wed Sep 02, 2015 4:17 pm

The AirSense 10 Elite is a full data machine and shows all the data that the AutoSet would show in terms of data. It just won't auto adjust the pressures since it only has cpap mode.

It's the AirSense 10 CPAP that is the half assed brick that you for sure don't want...the "CPAP" part of the model name instead of "Elite" is what to look for and it's easily seen on the machine itself.
Nice thing about ResMed is they put the model name clearly on the blower.

Odd that your insurance does the distinction between apap and cpap in terms of what they cover because the HCPCS code for each is the same E0601 but that's insurance for you.
I can see the bilevel distinction as those machine are a different HCPCS code.
Most insurance companies pay by HCPCS code and not model name or features but your insurance plan/company may be unique.
It is what it is though and it sounds like you have done your homework so just make sure it says Elite and you are getting a full efficacy data machine.

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PoolQ
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Re: Recently Diagnosed with OSA

Post by PoolQ » Wed Sep 02, 2015 4:38 pm

As for the rental, you really do want this. as soon as you show compliance AND you are sure that the machine you got is the one you want to keep you can convert it to purchase. The 10 month rental just sets the $ amount insurance pays during the 90 (or less) days. I am personally in the same situation with BCBS and am in the process of converting to BiPAP and very glad I did not buy an APAP.

Find out what the $75 is for. If it is your deductible then okay, if it is some processing fee or some other BS then see if you can get them to wave it or find another DME. Or just pay it and smile

they do not HAVE to preauthorize it BUT if your insurance denies it for some reason the DME will come after you for the full amount of their inflated cost. You should be able to speed things up by finding out when the form has been submitted to your insurance and calling up bcbs and doing some pushing.
Sleeping MUCH better now

JJenkins2005
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Joined: Wed Sep 02, 2015 1:20 pm

Re: Recently Diagnosed with OSA

Post by JJenkins2005 » Wed Sep 02, 2015 4:46 pm

Pugsy wrote:The AirSense 10 Elite is a full data machine and shows all the data that the AutoSet would show in terms of data. It just won't auto adjust the pressures since it only has cpap mode.

It's the AirSense 10 CPAP that is the half assed brick that you for sure don't want...the "CPAP" part of the model name instead of "Elite" is what to look for and it's easily seen on the machine itself.
Nice thing about ResMed is they put the model name clearly on the blower.

Odd that your insurance does the distinction between apap and cpap in terms of what they cover because the HCPCS code for each is the same E0601 but that's insurance for you.
I can see the bilevel distinction as those machine are a different HCPCS code.
Most insurance companies pay by HCPCS code and not model name or features but your insurance plan/company may be unique.
It is what it is though and it sounds like you have done your homework so just make sure it says Elite and you are getting a full efficacy data machine.
Question, what's the benefit of an Autoset if my MD has prescribed a set number? Is it more of the fact that if it doesn't work, they can switch to Auto and do a range of pressures?

ramblingasian
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Re: Recently Diagnosed with OSA

Post by ramblingasian » Wed Sep 02, 2015 5:01 pm

JJenkins2005 wrote:Question, what's the benefit of an Autoset if my MD has prescribed a set number? Is it more of the fact that if it doesn't work, they can switch to Auto and do a range of pressures?
I guess it's more to do with the fact that your needs may change over time and with an APAP, you can self-titrate easier versus having one fixed level.

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Pugsy
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Re: Recently Diagnosed with OSA

Post by Pugsy » Wed Sep 02, 2015 5:24 pm

JJenkins2005 wrote:what's the benefit of an Autoset if my MD has prescribed a set number? Is it more of the fact that if it doesn't work, they can switch to Auto and do a range of pressures?
Yeah..that's pretty much it. Some docs are hell bent on prescribing a single pressure and not a range of pressures because that's what they want/choose to do.
Some do it because they believe that a single fixed pressure is better and some do it because if a single fixed pressure doesn't work well then they get to tell you to come in and have another sleep titration study to try to figure out what is wrong or if another pressure is maybe better. Guess where they make their money from...yep, reading those titration reports.
Sometimes the sleep lab titration folks get it right and sometimes they don't. They didn't get it right for me but that sometimes happens.

Example...sometimes people have different pressure needs for different parts of the night. Maybe they need more pressure when they sleep on their backs and while maybe they prefer side sleeping they sometimes end up on their backs. Or maybe they are like me and sometimes need more pressure during REM stage sleep.
Supine sleeping and REM stage sleep are the 2 most common areas where OSA can be worse than an either side sleeping or other sleep stages and sometimes more pressure is needed to deal with those "worse OSA" events. Not always but sometimes. With a fixed pressure machine a person has to use the higher pressure (if needed) all night instead of part of the night. Not a big deal really if the pressure difference isn't all that great but it can be annoying if there's much of a difference. Like for me sometimes I would see a substantial increase during probable REM stage sleep which goes along with my initial diagnostic study where it was found that my OSA was about 5 times worse in REM sleep than in other stages of sleep. I could go along with 10 or 11 cm pressure just fine and then in REM the machine goes up to 18 cm...I sure wouldn't want to use 18 cm all night just to cover those REM sleep needs. Same thing can happen with supine sleeping and sometimes staying off our backs is easier said than done.

So for me...having apap mode is of great benefit due to my wide range in pressure needs but I could use cpap mode if I had to. I would probably whine and bitch and moan and groan but I could do it.

You may or may not even have the same need for apap mode...it's nice to have it available but not the end of the world if we don't.
Finally some people don't even like the varying pressures anyway. Some people find that even the slightest pressure change would disturb their sleep so they sleep better with a fixed pressure.

Some docs don't understand how apap mode works and believe cpap mode is superior but getting them to change their way of thinking is really difficult.

The Elite is still a great machine and there's a good chance that you won't even be one of those that might need more pressure only at some times during the night. If you are...well then your insurance can buy you another machine. Once you meet their criteria they have set out. We can only do what the docs and insurance companies will let us do. Yours is particularly rigid in their apap requirements...it is what it is.
I suspect you will do just fine with cpap mode...if not then you can cross that bridge when/if you come to it.

One can also titrate on a fixed cpap mode machine...takes a little more time to maybe come up with a suitable pressure but it can still be done...like if you start seeing nasty clusters of events during part of the night or pressure needs might change due to weight change...it can still be done just maybe not as quickly.

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yaconsult
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Re: Recently Diagnosed with OSA

Post by yaconsult » Wed Sep 02, 2015 7:02 pm

Everyone who uses an automode machine and checks the data can tell you that the pressure moves all over the place. Pressure needs can change with sleep state, sleep position, how much you've had to eat or drink, if you have a cold or the flu, etc. I have my pressure set from 13-20 and I have seen it go as high as 18.

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