Newbie with some questions

[macsnjets]

Hi, I'm not really new to OSA. I was diagnosed about 12 years ago and at the time decided to go for surgery rather than a cpap machine. I'm 47 now but at the time when I was young(er) I had a uvulectomy and my deviated septum fixed. It worked temporarily. Maybe for a few years but my OSA is back full force. I wanted to get another in lab sleep study done but I find out my insurance won't pay for that unless I have one foot in the grave. They will however pay for a home test. So my primary care physician is looking as to where I can get my home test paid for by my insurance. My first question is after I do the home test to prove to the world that I have OSA, who is going to prescribe the CPAP ? My Primary care Doc is just family medicine. Will I need to go see a specialist with my results ? When the Doctor prescribes the CPAP do they choose the machine or will I have the opportunity to pick it and being there are so many out there, if its my choice, what direction do I go ?

Thanks

[Pugsy]

Any doctor can prescribe the cpap equipment.
You can take the RX to any DME who supplies cpap equipment. You would of course want to work with a DME that your insurance will accept as an in network provider (if you have such insurance that has in network vs out of network) so you will have the least out of pocket expenses.

Probably should read this.
http://maskarrayed.wordpress.com/what-y ... me-part-i/

Check directly with your insurance coverage to find out exactly what they cover and pay for and do the math...it might be cheaper to by online especially if insurance is a rent to own and it goes into 2013 and a new calendar deductible gets factored in.

Don't rely on a DME to advise you on your insurance coverage...they have no way to know the exact plan.
Do your own homework so you know exactly what to expect.

If your PCP is going to be doing the RX for the machine....you can gently tell him that you would prefer so and so brand and model and then Dispense as Written to insure that you get what you want without hassles from a DME.
Study up on the machines who you know which one you want. You want full efficacy data for sure...especially with your history.
Might want to read this about full data capable machines.
http://maskarrayed.wordpress.com/

[Sheriff Buford]

Your doctor situation is like mine. My primary doctor ordered the test and prescribed the cpap equipment. Research here and tell your doctor what you want in case he doesn't know. Tell him you want a data-capable machine (Resmed S9 Autoset). If he asks why you why an autoset, then tell him you want it for comfort and you can use the autoset in the cpap or cpap mode... which ever you choose. Tell him you want the ability to use them both and you want the data. Have him write a separate prescription for your mask and put: "Mask of patient's choice" on the prescription. Call your insurance company and ask them what machine they will prescribe and what is the frequency of new masks, hoses, filters, etc... is allowed. Again, do as much research her before the doctor's visit.

Sheriff

[macsnjets]

Thank you very much for the replies. It looks like the key factor will be "Dispense as Written". I just spoke to my insurance company and the rep told me that the equipment is covered 100% as medically necessary. Is it safe to say as long as my primary writes a RX for a Resmed S9 Autoset, Dispense as Written, then its necessary ? I see you both use the S9 and my research says thats what to shoot for. I more than likely can have my primary write the RX and more the reason to go with an auto set since I won't be going to a lab to help set my pressures. Anyway, wish me luck.

Thanks again

[Pugsy]

Is it safe to say as long as my primary writes a RX for a Resmed S9 Autoset, Dispense as Written, then its necessary ?

Pretty much the medical necessity is the diagnosis of Obstructive Sleep Apnea medical code and any accompanying confirmation information that your insurance may require. Normally they pay by the E0601 code which is the same for the S9 Autoset as it is for the S9 Escape brick that doesn't offer any data. Insurance companies rarely care about cpap/apap models. It is the DME that "cares" about the model since the brick costs them less so they make more money selling the brick. Insurance pays them the same for the brick as they would get paid for the AutoSet...so you see where their preference will trend.

So essentially once you meet insurance requirements that they may have for proving the diagnosis...the model is irrelevant.
This pertains to the common single pressure cpap/apap machines.
Bilevel pressure machines a whole different story.