Using new insurance for full replacement cpap

Folks,

I switched jobs and insurance about 2 years ago. Since being on the new insurance, I have filled no DME claims.

My old cpap is about 4 years old and is making whirling noises after it took some jarring from checking the device as luggage on a recent flight.

I have a DME that is a couple of miles from my home. I gave them a call -- I won't mention their name since they are a direct online competitor with CPAP.COM. They have a sister company next door that does insurance billed cpap equipment.

The DME researched my insurance and pre-verified that I could not only get a new unit, but all the supplies, humidifier, and mask as a full replacement under the new insurance.

I got my doctor to write a prescription for me -- my old prescription and sleep study are missing from my medical chart. The sleep lab just called and said they found the sleep study. I am picking it up tomorrow. I will give a copy to my DME and Doctor. I made this sound easy, but it took a long time for the sleep lab to locate the study from 2004.

Anyway, I talked to the doctor and he wrote me a prescription just the way I wanted it (or was told by the DME I needed for Auto Cpap). He wrote;

Auto Cpap, 8cm, Heated Humidifier, mask, and supplies.

I asked him to write this because it contained all the details the DME said it neeed. Now, the DME is asking me do I want Auto or 8cm cpap.

What should I say? I want an Auto to record data and self-titrate. I understand my pressure is low. I suppose my original sleep study will indicate the pressure for cpap.

I am trying to make sure that I get what I want. I mean, althought it is covered by insurance, I am still paying premiums and my employer pays about $300 per month for me. It is not like I am getting something for free or screwing them.

Do you have any advice on what to tell the DME?

Thanks in advance.

You didn't say WHICH (brand/model) Auto/APAP you were thinking about, but if it's a Respironics, I'd ask for the REMstar M Series Auto w/A-Flex, but set to your prescribed single pressure in CPAP mode.

I would THINK that would work.

Den

The beauty of Auto CPAPs is that they can be set to run at an auto range or they can be set at a single pressure.

To me, your script says to give you and Auto set at a single pressure.

It sound like your DME may not know this. Do not settle for a straight CPAP!

Tell them you want an Auto. Tell them you want it set at constant 8cm pressure.

If they insist on giving you something other than the auto you want (and that your doctor ordered) go to another DME. You have a right to have your script filled as written.

Wayne

Yes, I am asking for the M Series Auto with Aflex.

I have told the DME that I am serious about getting exactly what I want. In fact, I have told them that I have a $300 deductible for the unit, and that I would rather pay the full $600 for the unit out of pocket rather than pay $300 to get something they want me to get. I told them that I am aware of the insurance codes being the same for this unit and all other units.

Since I have a prescription for Auto Cpap, I expect to get one. If they try to push off something else, I will not accept or sign for it.

I am paying the $300 using Flex Benefits (before-tax money dedicated to healthcare expenses). I have budgeted $1600 for Flex Benefits this year. You have to use the money or lose it. I am dead serious about just buying the unit from CPAP.com if they try to screw with me.

I don't mean to sound like an a$$, but I had a horrible experience with my first CPAP and mask just showing up on my porch about 2 months after my sleep study.

Really research the autoPAPs, inquire as to which brand this DME supplier usually provides. Decide which one you want then have your doctor re-write your equipment order similar to the below suggestions.

1] Respironics REMstar M Series Auto w/A-Flex (w/integrated humidifier if you prefer)
2] Set pressure 8 cms
2a] Minimum pressure (whatever your doctor has determined)
2b] Maximum pressure (whatever your doctor has determined)
3] A-Flex setting 3 (or whatever your doctor suggests)
4] Ramp off (unless you prefer it on)
5] Show AHI/Leak feature On
6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifier. If so just add "w/integrated humidifier" to the REMstar Auto w/A-Flex)
7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

1] ResMed S8 AutoSet Vantage (w/integrated humidifier if you prefer)
2] Set pressure 8 cms
2a] Minimum pressure (whatever your doctor has determined
2b] Maximum pressure (whatever your doctor has determined
3] EPR setting 3 (EPR does NOT work in auto mode, but if and when you opt to use the Vantage in straight CPAP mode you might want to use the EPR function)
4] Ramp off (unless you prefer it on)
5] Efficacy & Usage Data access
6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifer. If so just add "w/integrated humidifier" to the Resmed S8 AutoSet Vantage)
7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

You will notice the similarities to each suggestion.

1] Exact brand and model of machine
2] Scripted pressure (the autoPAPs have a pressure range rather than a set pressure)
3] Scripted amount for lower pressure at exhalation
4] Starts w/4 cms or other cms of pressure and ramps up to your set pressure after you get to sleep
5] Allows you to access your nightly data via the LCD screen
6] While the integrated humidifiers are most convenient for travel and take up less space on your nightstand, in really dry situations sometimes they can't provide as much humidity as you might need or want. For many the integrated humidifiers are more than satisfactory).
7] This ensures that you can try several masks, including a Full Face mask (sometimes they insist on a script specifying full face if the script just says mask, or will only provide the exact mask mentioned in the equipment order).