No Medical Necessity to replace a Brick

Hello all,

I addressed the issue of my non data capable machine with the PA at the sleep clinic. She says that there is no medical necessity for a data capable machine that costs "thousands of dollars."

I raised the point that the MaskFit, AHI stats are valuable information for a CPAP user to have, especially for fine tuning on a day to day basis, but she says that these values tend to not be accurate and she found them to not be useful in her years of experience. Therefore there is no medical necessity to change out the CPAP machine. I could get a replacement if either I or my insurance company were able to pay for it just based on my wishes.That involves returning my current used machine, then pay the difference.

I'm not sure at this point. I would feel much more strongly if I could get to the point where I keep my mask on the full night and have several hours worth of data per night to review.

On a positive note she thinks that I might be cured of needing a machine by simply losing weight. It's true that I have a lot of weight to lose; by BMI is 32. Unfortunately, my energy level as a result of sleep apnea causes me to look to food for fighting fatigue, and the lack of energy makes it all the more difficult to turn down food. Others have observed this too. Inversely, some people lost significant weight as a "side effect" of CPAP therapy.

davep700 wrote:Hello all,

I addressed the issue of my non data capable machine with the PA at the sleep clinic. She says that there is no medical necessity for a data capable machine that costs "thousands of dollars."

I raised the point that the MaskFit, AHI stats are valuable information for a CPAP user to have, especially for fine tuning on a day to day basis, but she says that these values tend to not be accurate and she found them to not be useful in her years of experience. Therefore there is no medical necessity to change out the CPAP machine. I could get a replacement if either I or my insurance company were able to pay for it just based on my wishes.That involves returning my current used machine, then pay the difference.

I'm not sure at this point. I would feel much more strongly if I could get to the point where I keep my mask on the full night and have several hours worth of data per night to review.

She is giving you a line of BS...the difference in cost between a brick and a data capable machine is a few dollars. In fact...the insurance companies consider them the same and pay the DME the same amount for each. The reason for the DME to give you a brick is that the make a few extra dollars by giving you the brick. See if you can get your doctor to write a prescription for a data capable machine. Then the DME must comply with the prescription.

Thanks. Seems that the sleep clinic, DME and insurance company are of the same opinion that a data capable and non data capable machine are equivalent. Maybe manufacturers should stop making two classes of CPAP machines.

I guess I should look to my PCP for assistance with a prescription.

What would your insurance be doing in terms of helping with costs if you didn't already have a machine?
What is your deductible?
What would be your co pay IF you could get a RX for a full data machine and run it through insurance.
Do the math...it might be less costly to just buy out of pocket another blower unit that you could use with your existing humidifier.

Full data machines don't "cost thousands of dollars" even if brand new. The PA at the sleep clinic...well let's just say not fully informed as to actual costs or what these new machines can do....or he/she has been out in the rain too long (as in all wet).

viewtopic.php?f=1&t=109450&view=unread#unread

Check out this thread above...that machine is a full data machine and while primarily a fixed cpap machine like you are currently using it does have some limited apap mode capabilities.

Her ignorance showed up the minute she told you to just lose weight.

I am sorry they are giving you such a hard time.

I agree with Pugsy, LSAT and Julie.

Without data, you and your doctor can not assess your treatment and when you think about it this is the medical necessity justifying data capable machines.

Talk to your PCP. This is between you and your doctor and if your doctor is not in agreement with you consider finding a better doctor.

Even if you get an RX from your doctor for a data capable machine it's going to be an uphill battle with the DME who now has to accept a used brick and give you a brand new data capable machine withou making a single penny more. (BTW, the RETAIL difference between a brick and a data capable machine is about $35. You do the math on the wholesale difference. The DME foisted tge brick on you to make an extra $10 or $12.

Anyway, you're going to have to grow a pair and get fully educated to have a snowball's chance of getting your DME to replace the brick, RX or not. So if you're not the assertive type, consider other options like buying your own blower with data to go with the humidifier you already have. Secondwind.com is a place to look.

davep700 wrote:I raised the point that the MaskFit, AHI stats are valuable information for a CPAP user to have, especially for fine tuning on a day to day basis...

As a matter of strategy -- From the perspective of so many providers, the CPAP user doesn't need any information about what the machine is doing, wouldn't understand it anyway, and certainly has no business fine-tuning on a day to day basis. Remember, we're not even supposed to know how to access those settings. So I would not make me, 'the CPAP user' the focus of my argument if I was trying to convince the PA of the need for a data capable machine. Instead I would point out that the doctor (or whoever the provider is) has no way to evaluate the treatment he or she has prescribed. That's it. There is no way the PA can refute that argument, because it's true. The objective measure of successful CPAP treatment is AHI < 5. AHI is not available on a brick.

Your PA sounds like she won't budge anyway, but for anyone in a similar bind, it's helpful to think about how to approach this strategically. Appeal to the provider in terms of how their hands will be tied when it comes to evaluating your treatment and/or troubleshooting problems, not how your hands will be tied.

Unfortunately, you're dealing with the medical mafia here.

Julie wrote:Her ignorance showed up the minute she told you to just lose weight.

My wife just lost 115 pounds abd I've had to raise her issue to keep get ahi below 5. She is going to sleep dr tomorrow

kaiasgram wrote:

davep700 wrote:I raised the point that the MaskFit, AHI stats are valuable information for a CPAP user to have, especially for fine tuning on a day to day basis...

As a matter of strategy -- From the perspective of so many providers, the CPAP user doesn't need any information about what the machine is doing, wouldn't understand it anyway, and certainly has no business fine-tuning on a day to day basis. Remember, we're not even supposed to know how to access those settings. So I would not make me, 'the CPAP user' the focus of my argument if I was trying to convince the PA of the need for a data capable machine. Instead I would point out that the doctor (or whoever the provider is) has no way to evaluate the treatment he or she has prescribed. That's it. There is no way the PA can refute that argument, because it's true. The objective measure of successful CPAP treatment is AHI < 5. AHI is not available on a brick.

Your PA sounds like she won't budge anyway, but for anyone in a similar bind, it's helpful to think about how to approach this strategically. Appeal to the provider in terms of how their hands will be tied when it comes to evaluating your treatment and/or troubleshooting problems, not how your hands will be tied.

PA already said that she wouldn't use the data anyway for evaluating treatment because it's inaccurate and unreliable. Apparently many people getting treatment at this clinic are receiving data-less machines and being evaluated for their treatment based on, I suppose, their hours of use and how they feel.

If this AHI info is truly medically necessary then why do manufacturers continue to make crippled machines over a $35 difference? Has the data not been embraced and adopted by the medical establishment due to cost, corruption or due to given or other reasons?

davep700 wrote:

kaiasgram wrote:

davep700 wrote:I raised the point that the MaskFit, AHI stats are valuable information for a CPAP user to have, especially for fine tuning on a day to day basis...

As a matter of strategy -- From the perspective of so many providers, the CPAP user doesn't need any information about what the machine is doing, wouldn't understand it anyway, and certainly has no business fine-tuning on a day to day basis. Remember, we're not even supposed to know how to access those settings. So I would not make me, 'the CPAP user' the focus of my argument if I was trying to convince the PA of the need for a data capable machine. Instead I would point out that the doctor (or whoever the provider is) has no way to evaluate the treatment he or she has prescribed. That's it. There is no way the PA can refute that argument, because it's true. The objective measure of successful CPAP treatment is AHI < 5. AHI is not available on a brick.

Your PA sounds like she won't budge anyway, but for anyone in a similar bind, it's helpful to think about how to approach this strategically. Appeal to the provider in terms of how their hands will be tied when it comes to evaluating your treatment and/or troubleshooting problems, not how your hands will be tied.

PA already said that she wouldn't use the data anyway for evaluating treatment because it's inaccurate and unreliable. Apparently many people getting treatment at this clinic are receiving data-less machines and being evaluated for their treatment based on, I suppose, their hours of use and how they feel.

If this AHI info is truly medically necessary then why do manufacturers continue to make crippled machines over a $35 difference? Has the data not been embraced and adopted by the medical establishment due to cost, corruption or due to given or other reasons?

Dave,

Ask the PA what the evidence is for her position? Not sure how to ask that question in a non confrontational way but maybe someone has a suggestion. Her position is also absurd because that would be like my saying to my doctor that my blood pressure is fine due to my feeling great even though I didn't measure it.

I have seen several sleep doctors and none of them had the attitude that I shouldn't have a data capable machine. Now a few of them may have been threatened that I knew how to change the pressure but that is another issue.

49er

davep700 wrote:If this AHI info is truly medically necessary then why do manufacturers continue to make crippled machines over a $35 difference? Has the data not been embraced and adopted by the medical establishment due to cost, corruption or due to given or other reasons?

Because DMEs and Sleep Clinics continue to buy them.

If you owned a sleep clinic...which would you buy...when the bulk of your income is from sleep studies and the sale of a machine?
If they sell you a brick and you aren't doing well then they get to say "let's do another sleep study to see if we can figure out why you aren't doing well"...
or they could sell you a full data machine and look and find out the problem is maybe a leak issue and they don't get to do another sleep study.
It's all about the dollars.

While the difference in cost at a wholesale level is all that great...and insurance pays the same no matter whether the machine is a brick or full data...multiply that slight difference by 1,000 machines and there is a substantial potential income difference. It's all about the dollars and not what truly might benefit the patient.

CPAP machine manufacturers don't count us the end user as their customer...their customer, that they cater to, is the DME and sleep clinics.

49er, I'm not sure yet what evidence for her position is that the data tends to be inaccurate.

On this forum I heard that machines might miscategorize apneas, hypopneas and centrals, but that's about it.

I could certainly use your argument if and only if I knew the measurement data I can get is reliable.
I might look for some studies or articles on the use of the data in CPAP therapy (??).

Fortunately, I am going to my visit my PCP tomorrow. I assume I need to inqurie about a prescription worded as, "data capable CPAP machine @ pressure 12cmh2o".