Insurance and masks with multiple pillow sizes

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Which mask are you asking about?

desiderata wrote:My insurance circumstances changed and I'm going to try using it for cpap supplies. When I've ordered a new mask on cpap.com it always comes with multiple nasal pillow sizes. Is this also the case for brick and mortar DMEs, or can they legitimately withhold the sizes that I don't use? (If they should be included then I'd pass them on to others who can use them.) Or do they charge differently for what is essentially the same medical equipment catalog/reference number and therefore decide they can keep the extra sizes?

The extra pillows should be yours.
Heavily used post... viewtopic/t158303/viewtopic.php?f=1&t=3 ... e#p1217838

It depends on the mask you get.

My DME tried to rip me off at first - First mask was the dreamwear cushion and they only gave me the one nose piece. When I realized later that the set was supposed to come with EVERY size (5-6 sizes, if I remember), I called them to ensure it wouldn't happen again in the future. Now, I check and double check when ordering masks and don't leave the store until I'm sure that I have everything I'm supposed to be receiving.

It depends on the mask package that the DME buys and keeps in inventory.
Some mask manufacturers will package with one size pillow and some will package with the 3 different sizes.
So it depends on which package the DME decides to keep in stock. Most seem to keep the package with 3 sizes because the cost to them probably isn't all that different and it's easier to be able to "fit" more people with the multiple sizes.

This is a couple of years old but look on page 11 for the AirFit P10 that I use and look at the packaging options.
Prouct 62910 AirFit P10 for her nasal pillow system will include the 3 sizes...XSmall, Small and Medium...this is the complete mask with headgear and frame/short hose.
They don't seem to offer the headgear and frame with just one nasal pillow in the P10. Another brand or another model might or at another time. This list is 2015...they might even offer it now .....but using this list as an example.
They do offer the frame with one pillow but no headgear.

Most DMEs will keep in inventory the complete package and it comes with the 3 sizes.
Insurance pays by HCPCS billing code and DMEs always break down the parts when billing insurance even if they come in one package. It's just the way it is done. There's no HCPCS billing code for a complete mask package.

Now for is it ethical for the DME to keep the other 2 sizes in a package that maybe you don't need....I don't think so. My DME told me that it is against the rules to open the package and remove anything or to sell a package that has been opened. I always get all 3 sizes when I get a new mask package.
When DMEs pull out the other 2 pillows and sell them outside the package...it's against the rules because those pillows aren't in a sealed environment.
My DME won't do it. Others yeah they do it all the time but if the pillows aren't in a package there is no proof that they aren't used.
They do it to make a little extra money.

So I would suggest that you don't accept a package that has been opened and don't let them open it in front of you and remove anything.
You have that right. Tell them "no, don't remove anything...I might want to try those other sizes"

My DME told me it was against the law...now whose law I don't know and I have never seen it in writing. They once gave me a brand new mask package because it was the only one they had in the mask I was requesting. It had been opened for demo purposes but never used. I offered to pay for it but he told me "no, it's been opened and we can't legally sell anything that has been opened"...so I got it for free.

My DME replaces the sizes I do not need with the size I use,
and bills Medicare for every single part, according to the breakdown.
The only exception is that once they GAVE me the headgear
because it had not been six months since my last mask purchase.

The last time I ordered a mask I got what I asked for except it all came in separate packaging. Frame separate, small hose, pillows, etc. And the pillows were all the same size. I remember several years ago when I ordered this mask (Swift FX) everything came in one large bag, including different size pillows. Don't understand how one DME can send one thing and another can send the same thing but in entirely different packaging. I've been using Versus Healthcare the last few years. I think I'll call them on Monday and see what they have to say.

This may be a little OT - but more a Nit Pick on my part.

What ever happened to the nice little bags or zipper containers that used to come with new FFMasks... I think ResMed is cheeping out on us a little unless they lowered their price because they stopped including the bags.

I have quite a collection of the little buggers and I used them not only for storing my Mask when traveling but also for my camera lenses and other things I don't want to get scuffed up. I miss the little soft draw string bags... Wish they'd bring them back.

I have a question regarding Swift FX pillows - my DME tells me they can't give these to me any more because "insurance (Medicare/Blue Cross) won't pay for them." Not that they are discontinued, just that they won't pay. I find them still on the CPAP website for sale so what's the deal? Anybody know? I have used these since I started 6 years ago and am upset about not being able to use them any more - am on my last one!

I would contact your insurance provider on your own and verify that story in person. Some times DME's will tell all sorts of stories for all sorts of reason. They may not have them and want you to change. It may be that fewer people are using them so they're not making as much money on them etc...

CarCulmer wrote:I have a question regarding Swift FX pillows - my DME tells me they can't give these to me any more because "insurance (Medicare/Blue Cross) won't pay for them." Not that they are discontinued, just that they won't pay.

Well you are being told a falsehood.
Medicare will indeed pay for them. I just got 6 of them in December and Medicare paid their share.
As to why they want to lie to you....your guess is as good as mine. I suspect they simply don't want to stock them for some reason.

Medicare doesn't care about brand of nasal pillow...they just go by the allowance schedule and its 2 per month.
Medicare doesn't care about brand and model of anything.

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Horsefeathers!
Your DME does not want to special order them.
THEY ARE LAZY/CHEAP!
Call Medicare and report them.
This is not allowed, per Medicare guidelines.

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Sorry, but CarCulmer has a crappy, LYING DME,
who should be reported to Medicare!