CPAP for 20%, APAP for 100%, or keep trying?

EarlyStarts · Post by **EarlyStarts** » Mon Feb 25, 2008 6:50 pm

Hello!

I have had an old Remstar plus CPAP machine set at 9 since 2004 when I had my one and only sleep study. I have used it almost every day since day one and have had very few issues with it and I feel much better now.

After a recent camping trip in the desert, the blower motor started to make a loud grinding noice and when I talked to the DME, they said I need a new one. The machine has had a rough life as I travel too much so it has been dragged all over the world including a few trips around Europe and at least a half dozen times to China. My insurance will pay for 80% of whatever I need but I need an up to date prescription. (I can use my old prescription to buy whatever I want out of my own pocket but I need the new prescription for insurance purposes).

As long as I was getting a new machine, I wanted an APAP as I think my needs vary depending on sleep position, alcohol, colds and other things.

I went to the sleep doctor today to get a new prescription but was unable to get him to give me one for an APAP. I tried using all the arguments but could not get him to budge. He did give me a prescription for a new Respironics Pro CPAP at 11 and with C-Flex at 2 and smartcard. He specified it all by name on the prescription. He wants to see me in 6 weeks to look at the data.

I have Encore Pro and a card reader but have not used them yet. Is the data output of the straight CPAP machine any different from the APAP output?

I guess my options are:

1) Just get the M-series Pro CPAP to start monitoring and adjusting to find my optimal pressure and be done with everything.
2) Buy the M series APAP out of my own pocket. (this could be done in conjunction with option #1 to end up with a back-up machine)
3) try another doctor to see if I can get an APAP prescription.

Suggestions?

GeneS · Post by **GeneS** » Mon Feb 25, 2008 7:22 pm

It sounds like you have a good job and can do what you want. If it were me I would buy the machine that I really wanted from cpap.com and get the best one I could get from the insurance as a backup machine. I would do it before March 1 because there is a lot of talk about large price increases. Try to get machines that work with your card reader and software. I went years without using software but it is much better to use it to figure out how you are doing and if you need to change anything.
GeneS

Wulfman · Post by **Wulfman** » Mon Feb 25, 2008 7:30 pm

Will your insurance reimburse you for out-of-pocket purchases?
If they will (at whatever percentage applies to DME), since you have a prescription for a CPAP, you can buy an APAP from CPAP.COM......and submit a bill to your insurance provider for what you paid. You can use the invoice from CPAP.COM as an example because all of the insurance codes are listed on it .....then generate a bill of your own with you as the billing party and your insurance provider as the party being billed.

If you happen to have Blue Cross, they are usually very good at doing it this way.

I don't have Blue Cross (employer is self insured)......and I did it this way 3 years ago. It saved everybody money.

Den

RipVW · Post by **RipVW** » Mon Feb 25, 2008 7:32 pm

Hello EarlyStarts,

Yes, I agree with Gene! The M Series Auton CPAP with AFLEX is a DREAM MACHINE! Got my in October, haven't looked back. Yes, the software, card and reader are the same for both of the Respironics machines.

Slinky · Post by **Slinky** » Mon Feb 25, 2008 8:21 pm

Get your familyl doctor to write you the script for the A-Flex, it doesn't have to be a sleep doctor writing the order. Pooh on your sleep doc. Buy the Pro yourself for backup and travel, its cheaper outta pocket than the A-Flex.

Suggested script:

1] Respironics REMstar M Series Auto w/A-Flex (w/integrated humidifier if you prefer)
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.

EarlyStarts · Post by **EarlyStarts** » Tue Feb 26, 2008 1:29 pm

I guess what I really want is the data recording capability. Even with the CPAP Pro, I will be able to adjust the pressure and monitor the results to optimize my pressure. It may take a bit longer to zero in than if I had a APAP but it still should work well. I think I still get all the same AHI information with the CPAP.

I think I will get the CPAP ordered from insurance and see how it goes.

I considered buying the APAP and trying to get reimbursement from the insurance company but when I downloaded the forms, they looked daunting. And I don't really have a family doctor at the moment.

xyz · Post by **xyz** » Tue Feb 26, 2008 2:13 pm

> I went to the sleep doctor today to get a new prescription
> but was unable to get him to give me one for an APAP.

Step #1: Fire that doctor. In this day and age, there is no excuse for getting a non-data capable machine. (Unless a person has to pay for it themself and cannot afford it.)

Was that a sleep _specialist_ doctor, or just a doctor who sometimes sees OSA patients? I could see it if he was a primary care doctor who didn't know anything about OSA. I am doubtful that a real sleep specialist doctor would say that. Some pulmonary specialists, who do not sub-specialize in sleep issues, see OSA patients. It's doubtful that they know much more than primary care doctors.

Check his credentials. Ask him what _sleep-related_ organisations he belongs to. Check http://www.absm.org. Click on "verification of diplomates".

Do you have an HMO? Are you restricted by your insurance plan to a specific DME? The details can determine what you are able to do.

> I don't really have a family doctor at the moment.

It's a good idea to have one doc who kind of keeps an eye on everything, including the specialists you go to. In this case, it would give you another opportunity.

> I think I will get the CPAP ordered from insurance and see how it goes

I don't recommend it. Most insurance plans won't pay for another machine for 5 years.

EarlyStarts · Post by **EarlyStarts** » Tue Feb 26, 2008 3:04 pm

The doctor is a sleep specialist. He did prescribe a data capable machine in the Respironics CPAP Pro M-Series but just not the APAP machine. He is listed on the ABSM site.

I am not limited to a specific DME and plan to work with billmyinsurance.com.

I guess what I am struggling with is if it is worth the effort to try to get someone to prescribe an APAP (or buy it out of pocket and take a chance at getting reimbursed) when I have a prescription for a data capable CPAP in hand.

DreamStalker · Post by **DreamStalker** » Tue Feb 26, 2008 3:23 pm

EarlyStarts wrote:The doctor is a sleep specialist. He did prescribe a data capable machine in the Respironics CPAP Pro M-Series but just not the APAP machine. He is listed on the ABSM site.

I am not limited to a specific DME and plan to work with billmyinsurance.com.

I guess what I am struggling with is if it is worth the effort to try to get someone to prescribe an APAP (or buy it out of pocket and take a chance at getting reimbursed) when I have a prescription for a data capable CPAP in hand.

If you are going through billmyinsurance.com, all you need is the CPAP Rx to get any APAP you want.

It is only when dealing with greedy DMEs that they will insist you go back to your doc for an Rx that specifically requests an APAP.

Just ask you sleep doc for the Rx, it is yours and it is valid for life.

Wulfman · Post by **Wulfman** » Tue Feb 26, 2008 3:37 pm

Dittos to what DreamStalker said.

IF you had been given a prescription for an APAP and you got one, and then someday decided you wanted a less-expensive CPAP as a backup or for travel......you wouldn't be able to get one with an APAP prescription......but you CAN get an APAP with a CPAP prescription. In my opinion, you're better off without the APAP prescription......UNLESS you were trying to get an APAP through a local brick & mortar DME.

Den

EarlyStarts · Post by **EarlyStarts** » Tue Feb 26, 2008 3:41 pm

If you are going through billmyinsurance.com, all you need is the CPAP Rx to get any APAP you want.

It is only when dealing with greedy DMEs that they will insist you go back to your doc for an Rx that specifically requests an APAP.

Just ask you sleep doc for the Rx, it is yours and it is valid for life.

_________________

I think it is my insurance company who requires a prescription specifically written for APAP and a pressure range and that is why billmyinsurance is asking for it. You are right that I could use my current prescription for a CPAP to get an APAP from cpap.com but my insurance would likely not pay for it.

DreamStalker · Post by **DreamStalker** » Tue Feb 26, 2008 3:53 pm

EarlyStarts wrote:If you are going through billmyinsurance.com, all you need is the CPAP Rx to get any APAP you want.

It is only when dealing with greedy DMEs that they will insist you go back to your doc for an Rx that specifically requests an APAP.

Just ask you sleep doc for the Rx, it is yours and it is valid for life.

_________________

I think it is my insurance company who requires a prescription specifically written for APAP and a pressure range and that is why billmyinsurance is asking for it. You are right that I could use my current prescription for a CPAP to get an APAP from cpap.com but my insurance would likely not pay for it.

That's a first. The insurance code for an APAP and a CPAP are exactly the same. The insurance will pay the same amount regardless of whether it is an APAP or CPAP. Maybe Johnny Goodman can clarify this but since when did billmyinsurance start asking this?

Wulfman · Post by **Wulfman** » Tue Feb 26, 2008 3:56 pm

You might want to double-check with billmyinsurance on that. The insurance billing code is exactly the same for APAPs as CPAPs: E0601 NU

Den

Humidifier

Humidifier

Humidifier

Humidifier

CPAP for 20%, APAP for 100%, or keep trying?

CPAP for 20%, APAP for 100%, or keep trying?

I guess I will order the CPAP.