Where to Begin

[patatdac]

I completed a sleep study last Friday and the technician woke me up and congratulated me as qualifying for a CPAP. I didn't feel like I hit the jackpot at that moment, but I am moving on. I have been reading this site most of the weekend and found some wonderful folks on here that are sharing thier knowledge to help others. My present concerns center around the cost of the equipment and the one shot at getting it mostly right the first time. Specifically, selecting a machine. My understanding is that most insurance companies will pay (or partially pay) for a machine once every 5 years. I have read that some DME providers may try to sell you a low end machine as it beneficall for them. That may not best suit my needs. So, I want t see what the experienced users on this site think about the Resmed Airsense 10 Autoset with Climateline tubing. As I read on this site, the Airsense 10 Auto can function as a CPAP and an ACPAP. I am normally a stomach or side sleeper and don't know if I will ever be able to sleep on my stomach again. I do have congestion issues from time to time so I am pretty sure the full face mask will be my mask type. I used the full face mask during testing and could only lay on my back during testing due to all of the wires and mask. So sleeping position and occasional/frequent nasal congestion are issues that may help support the selection of a ACPAP type machine if these are valid assumptions. Don't know if my Physician and Insurance Co will see it this way. My follow-up appointment with the physician is a full month after the sleep study so I want to learn what is best for me and what the insurance company will pay for.
What do you thing of my selection of equipment and supporting issues? Thank you for taking the time to read this and for sharing your knowledge and experiences.
Patatdac

[robysue]

My understanding is that most insurance companies will pay (or partially pay) for a machine once every 5 years.

That's pretty standard. Some won't pay for a new PAP even at 5 years if the old one is still functioning correctly. You need to contact your insurance company to find out what their policy is.

I have read that some DME providers may try to sell you a low end machine as it beneficall for them. That may not best suit my needs.

This is sadly very, very true.

So, I want t see what the experienced users on this site think about the Resmed Airsense 10 Autoset with Climateline tubing. As I read on this site, the Airsense 10 Auto can function as a CPAP and an ACPAP.

The Resmed AirSense 10 AutoSet and the Resmed AirSense AutoSet for Her are both top of the line machines that record full efficacy data. The AutoSet for Her is a bit more flexible in that it has two Auto algorithms, and the "For Her" algorithm makes an attempt to identify so-called RERAs, which the regular Auto algorithm does not.

I am normally a stomach or side sleeper and don't know if I will ever be able to sleep on my stomach again.

My Hubby is a happy PAPer who spends a lot of time on his tummy with the mask on. The trick for stomach sleeping with a mask is to find a head position and a pillow combination that allows the mask to hang off the edge of the pillow. The standard CPAP-friendly stomach sleeping position is often called "the Falcon" sleeping position. Google "Falcon sleeping position" for more details. Here's a picture of it with somebody using a CPAP mask:

I do have congestion issues from time to time so I am pretty sure the full face mask will be my mask type. I used the full face mask during testing and could only lay on my back during testing due to all of the wires and mask. So sleeping position and occasional/frequent nasal congestion are issues that may help support the selection of a ACPAP type machine if these are valid assumptions.

Occasional congestion does NOT mean that you need to use a full face mask all the time. If you are usually a nose breather, you will most likely be much more comfortable using a nasal mask or a nasal pillows mask. You'll find these smaller masks are easier to fit and easier to seal. They are also usually easier to sleep with.

Many people (myself included) don't have too many problems sleeping with a nasal mask or a nasal pillows mask even when we've got some congestion. I suffer from seasonal allergies from spring (tree pollen) through summer (grass and weeds) through fall (ragweed), but I have no real trouble using my Swift FX nasal pillows mask all during the grown season. I do have to deal with the nasal congestion---through using a neti pot about an hour before I go to bed and antihistamines during the day when my allergies are at their worst. During bad allergy seasons I have also had to get a script for flonase. The benefit is that now that I'm treating my allergies to make it easier to sleep with the PAP machine, I'm feeling better in the daytime because I'm no longer simply suffering through my "mild-to-moderate" allergies.

You can always buy a FFM later if you decide that you really want one for dealing with significant congestion from head colds. (Hubby did that; he still has yet to try the dang thing though since he's not had a cold since we got it.)

It is also a big mistake to think that you must change your sleep position to accommodate the mask. Most of us have an intense dislike of sleeping in an unfamiliar position and attempting to change our sleep position at the same time as learning how to sleep with a six-foot hose attached to your nose makes it really easy to become very resentful of the PAP machine.

My follow-up appointment with the physician is a full month after the sleep study so I want to learn what is best for me and what the insurance company will pay for.

Use this time to contact the insurance company and find out directly from them what your durable medical equipment coverage is. Be sure to find out exactly how they pay for CPAP equipment. Try to get a list of in-network durable medical equipment providers (DMEs) and start making phone calls NOW so that you can find a DME that will provide you with the machine you want and that you are willing to work with.

There's a link in my signature for my standard advice to those newly diagnosed with OSA. Read it. There are a lot of tips for making sure that you get the equipment you want to be sleeping with for the next 5 years.

[AMK]

My insurance pays for one machine every five years, too. I called them and asked to be given the names of DME's that take this insurance. I also found out I could look up names on their web site. My doctor's office sends people to a certain DME that is far away from where I live. I chose the "for her" version of the same machine you are considering, and the doctor's office told me the far-away DME did not stock that machine so I would have to take an older model, which was strike two. I found a DME that is two miles away from where I live that takes my insurance and they readily agreed to order my machine. I work with them. The mask situation was tough because so many DME's do not stock a lot of masks anymore, and I had to find the mask I currently use through cpap.com. Many of their masks (all the newer ones) have return insurance with free shipping so it costs nothing to try new masks and return them. Since it originally took my DME so long to get a mask for me to try I will end up having to pay for my first mask out of pocket because I'll keep the one from cpap.com. Though the DME does have the 30 day return policy, that gets trickier when it takes them 2-3 weeks to get in a new mask to try, so I think I have been able to determine the mask that works for me and next year when I'm due for a new mask I'll just tell the DME what to order for me instead of needing to experiment again. I expected an initial outlay so none of this has me particularly upset...I'm just glad I was able to get a good machine; that was the important part financially. (And yes, I got the heated hose, too.)

[Cardinalphan]

I have now been on CPAP for 10 years. My biggest fear is forgetting it or some part of it when traveling. I have used several machines and my favorite is the Resmed S9 machine. Very quiet and has all the features you need, including the climate hose. I too suffer from congestion most days and have found the nasal pillows work just fine. No matter your choice, it will take a great deal of time to truly get use to the thought of the machine and falling asleep with the hose pulling on you. I suggest the hose hanger that keeps it elevated about 2 feet above your bed. $20 well spent at CPAP.com. I have also found that the aroma therapy also assists with any congestion you might have as it helps open your nasal passages. You will soon find what a good nights sleep can do for you. Amazing!

[Janknitz]

Don't know if my Physician and Insurance Co will see it this way.

In MOST cases, your insurance company doesn't care about which machine you get because they will pay the same amount whether you get the cheapest brick or the best bells and whistles machine. You should confirm this by calling and asking if they pay by billing code (ALL CPAP and APAP machines have the SAME billing code) or by make and model. Unless you have an HMO, the answer is usually by billing code. Don't let the DME talk you into paying the difference in price if you want the fancier machine. In most cases they are not permitted to "upcharge" or "Balance Bill". Your insurance company pays the set amount and then you are responsible only for a percentage of the amount the insurer pays, NO MORE.

Your doctor probably won't care. Most don't think it's necessary to have an APAP or data. Some doctors don't like APAP's, but you can use the machine in CPAP mode if that's what your doctor prefers. Some doctors don't think you should have access to your data for various reasons (they are intimidated by patients with some knowledge, they don't know how to read the data themselves, they think the data is unreliable, they are just plain ornery). So asking for them to ensure you get a data capable machine may be like beating your head against a brick. The only thing that certain doctors might see as useful is access to leak data, so you can be sure a leaky mask isn't interfering with your therapy. So that's what you should ask for--your doctor to write the prescription giving you access to leak data. Since leak data is only available on full data machines, you can take it from there.

If you haven't already, be sure to read my blog posts in my signature below.

[Guest]

Thanks for all the great replies. I have learned so much in such a short time. You are wonderful folks for sharing you experience, knowledge, and wisdom. Based on your guidance, I contacted my insurance company (BC/BS) and they informed me that another company (HiMark) handles an DME for them. I spoke with a HiMArk representative for about 20 minutes and they were very helpfull expalining the same code for all CPAP machines as has been mentioned multiple times on this forum. The key thing that I noticed during discussions is the HiMark rep mentioned multiple times is "medical necessity" when asking about frequency for replacing DME. It seems that the DME is responsible for determining medical necessity and it may be a good idea for me to develop a good relationship with the DME. That may not be too difficult, I hope as there are multiple preferred DME providers in my area. I saw somewhere on this site that I may need to request reporting capability access to the CPAP. Is this correct assumption that the DME has the capability to activate (or deny access) to machine capabilities for users? Do I request the physician spell out reporting capabilities on the prescription?

[ChicagoGranny]

It seems that the DME is responsible for determining medical necessity

Wooooo!

Let's sue that DME for practicing medicine without a license!

[ChicagoGranny]

occasional/frequent nasal congestion are issues

You need to see a good ENT/Allergist. No need to suffer and possibly impair CPAP therapy.

If you haven't been to an ENT in a long time, you will find things have changed and there are more and better treatment options these days.

[Janknitz]

Repeat after me: " the DME is NOT my friend"

Dme's are profit making businesses first and foremost. They make the highest profit by supplying you with the least expensive equipment. Since your insurer pays by hcpcs code, the cheaper the equipment and supplies they provide to you the more profit they make.

An EFFICACY data capable machine is more expensive than a "brick" (machine with compliance only data). So the DME will likely resist giving you a machine with EFFICACY data (there are some dme's out there that WANT their customers to have efficacy data machines so they can be truly helpful, but such dme's are the exception, not the rule).

Secondly, if you ask a DME to "give" you "reporting capability access" (we call that access to efficacy data around here) you'll get anything from a blank stare to being told it's illegal to access your own data. You may be told that a brick gives data (it does give compliance data but not EFFICACY data) or that an EFFICACY data machine has NO user accessible data. Lies, lies, and damn lies.

This conversation is generally a waste of time with a DME. It's up to YOU to learn what the latest model machines have the capabilities you want (my blog is out of date as to the latest models) and its up to YOU to find an in network DME who will supply what YOU want, rather than what the DME wants you to have because it enhances the dme's profit margin.

If YOU do your job well and get an EFFICACY capable machine, we can help you access the on board data AND point you to free software for even better data mining. Another reason the DME may not want you to access your own data is that they prefer to charge you to retrieve the data to give to your doctor (not you!).

If you prefer to be a mushroom, sit in the dark, and be fed BS, the DME is happy to oblige. If you want to be an active participant in your care, it starts here and now.

[wilsonintexas]

The one thing I have not seen in this thread so far is that you can avoid a lot of problems wit the DME if your DR is willing to work with you. (NOT ALL WORK WITH YOU. BUT MANY WILL.... IF NECESSARY FIND ONE THAT WILL )

THE DME MUST dispense what the script is for. So avoid the whole problem by getting what you want on the script.

while at the DR get at least two scripts - get hard copy of both, INSIST ON IT. DO NOT LET THE DR SEND IT DIRECTLY. This way, if there is a problem with the DME you can walk away and go to another DME.

My insurance company had 5 DME's. They could care less who I use.

The SCRIPTS YOU NEED:
1) the script for the specific machine you want including
- the specific make and model you want. (I am picking one.... you pick yours: )
- AirSense™ 10 AutoSet For Her CPAP Machine with HumidAir
- heated hose (get it even if you do not think you will use it.... on some machines it drives having a different power supply)
- humidifier
- the pressure settings
This script has the note: NO SUBSTITUTIONS PERMITTED.

Be careful, many scripts have a signature block that allows substitutions, and another one that says no substitution.

MOST DRS SIGN THE ONE ALLOWING SUBSTITUTIONS BY DEFAULT

2 - GET A SECOND SCRIPT
This one says:

- Any CPCP supplies requested by the paitient including any mask, hose, and supplies.
This one also has a note something like:
This script never expries.
or Expires in 2025


(I once had a DME say I needed the DR to write a specific script for the mask I wanted to try...... I pulled out my script and said... BS.... )

KEEP THE ORIGINAL OF BOTH. MAKE THE DME MAKE COPIES. DO NOT GIVE UP THE ORIGINALS. You may need them in a few years, when the insurance company drops or adds a new DME..... or the DME undergoes management changes and is not longer nice to work with.

So.
- Kow your rights
- avoid the whole thing by a tightly written script

RANT OVER.

You may need to send in a copy of the second one to people like CPAP.com if you decide to try a mask that the DME will not provide.

The DME may not like it, but they have to give you that machine.

If they try to pull some BS like:
- we have to charge you a premium for that machine..... (mine did it the first time) say.... Lets get the insurance company on the line right now and confirm that.

- If they say... we can not get that machine..... find a new DME or CALL THE INSIRANCE COMPANY right there and say that the DME refuses to fill a script as written.

ANY DME CAN GET ANY MACHINE.
If they try to pull this kind of stuff, be nice,. Tell then that you have talked to your insurance company already and know that the machine is covered. Tell them that if they choose not to fill the script as written, that is fine. But that you will file a complaint with the insurance company.

Give them a chance to check with their supervisor.

IT IS NOT WORTH ARGUING. THERE ARE OTHER DMES OUT THERE, WALK AWAY.

But then do CALL THE INSURANCE COMPANY AND LODGE A FORMAL COMPLAINT.

YOUR INSURANCE COMPANY PROBABLY HAS MORE THAN ONE DME. YOU GET TO PICK THE ONE TO WORK WITH.



I may be lucky, but I have a DR that worked with me. When I told him why I wanted the specific machine. When I came in with my laptop and brought up sleepy head software and asked him about breathing patterns, he said..... You are the first to do this, but it is obvious that you are taking this seriously.... so he worked with me.


If YOUR DR WILL NOT DO HIS FIND ONE THAT WILL.

ok, rant over.

But, I thik the key to this is to tie the DEM's hands behind their back and not give them any wiggle room.

[Hosehead4ever]

Note that cpap.com will let you buy any mask or machine as long as you *have* a prescription for a machine/mask/supplies. My doctor initially gave me a script for a specific mask and I wanted to try multiple masks. When I called cpap.com to find out if that was possible, I was told it was encouraged. Also was told that once cpap.com has a script, it is good forever. I haven't tried that last one but I have purchased several different masks (before I got a script saying 'patient choice').

[tuzacat]

I have been on this therapy since 2009 and have changed machines three times. I went from a Cpap to a Bipap and recently to an ASV machine. Each time I switched machines it had nothing to do with the DME. I felt like my therapy wasn't working, I went to the doctor, the doctor sent me for another sleep study - discovered I needed a different solution and prescribed a different machine. The DME simply filled the order. When I had trouble with the humidifier I called the DME and they replaced it. I don't know what would have happened after 5 years, though. Good luck with your therapy!

[Guest]

Great feedback. Thanks for all your responses. I think I got it now, The DME is not my friend... I am by nature suspiciuos of salespersons but maybe dropped my guard on this site. The idea of 2 prescriptions, one for the ACPAP and a second for misc supplies is brilliant. For the ACPAP prescription (besides identifying the machine) does the Dr. write the pressure setting(s) in the script? I do intend to look into clearing up the congestion with an ENT visit, but in the meantime, I am thinging that my first mask should be a full face until I get this under control. From browsing it appears that full face masks are more expensive than nasal masks and it may be more cost effective to get that first. Some browsing indicates the AirSense™ 10 AutoSet is availble with a regular hose or with a heated hose as part of the package. Can anyone confirm this? Also contacted Dr. office and they are fine with me pursing any DME. Thanks again.

[AMK]

Yeah a heated hose. The regular hose is the default, so the doctor needs to put the heated hose on the prescription. And yes the prescription shows your pressure settings.

The DME is not your friend but they also are not necessarily your enemy. It's a business relationship. Not much different than finding a good plumber, for instance. When I was starting out I got the impression from boards I was reading that I needed to take an adversarial stance, and I don't think that helped me.

Edit: I wanted to add that I only got one prescription and it's been fine for me. The DME has a copy, and I have a copy that I scanned and emailed to cpap.com. I'm not certain why one would push for two separate prescriptions. Mine takes up a full 8.5x11" sheet of paper and covers everything.

[princessbelle]

I too have BCBS out of Illinois, I don't live in Illinois so..... here goes I get the benefits of my home state which are less than MY policy which the employer and my husband pay for. If you live in the same states as your BCBS insurance you shouldn't have this issue.