A DME Brick Intervention

[SleepingBetty]

I completely agree here. I had the same problem battling for a month with my old DME in getting my BiPAP switched out for an Auto BiPAP. The DME kept claiming that my Sleep Study did not warrant switching to an Auto. I even called my insurance company and spoke to them about switching...Insurance company said they don't really care what machine I use and they only have one code for a CPAP machine - as long as my doctor writes a RX. Finally my Sleep Doctor got pissed off and personally called the DME and reminded them that SHE was the DOCTOR and THEY were to MEDICAL SUPPLIER and to submit my new RX to my Insurance company. My Auto BiPAP was miraculously approved my machine in an hour and shipped it that same day.

CALL YOUR INSURANCE COMPANY.....do not take your DME word for anything.

Hi, Kenwood! First of all, I am truly sorry that you or anyone else has these kinds of problems with their DME's. Secondly, see the reply above to Hose_Head. It's that ONE code for a CPAP machine that is a large part of the problem... at least with our insurance. As far as they are concerned, it's one and the same machine and they don't seem to care that the doctor has written a new Rx for an AUTO machine. The DME even said they have been trying to get that changed for years because they obviously are not the same machine and it causes these kinds of problems. That's why I said we might have to get a letter of medical necessity. Insurance companies have WAAAYYYY too much control over the quality of an individual's health care! And it's not even an HMO! HMO's are even worse!

[Kenwood]

I completely agree here. I had the same problem battling for a month with my old DME in getting my BiPAP switched out for an Auto BiPAP. The DME kept claiming that my Sleep Study did not warrant switching to an Auto. I even called my insurance company and spoke to them about switching...Insurance company said they don't really care what machine I use and they only have one code for a CPAP machine - as long as my doctor writes a RX. Finally my Sleep Doctor got pissed off and personally called the DME and reminded them that SHE was the DOCTOR and THEY were to MEDICAL SUPPLIER and to submit my new RX to my Insurance company. My Auto BiPAP was miraculously approved my machine in an hour and shipped it that same day.

CALL YOUR INSURANCE COMPANY.....do not take your DME word for anything.

Hi, Kenwood! First of all, I am truly sorry that you or anyone else has these kinds of problems with their DME's. Secondly, see the reply above to Hose_Head. It's that ONE code for a CPAP machine that is a large part of the problem... at least with our insurance. As far as they are concerned, it's one and the same machine and they don't seem to care that the doctor has written a new Rx for an AUTO machine. The DME even said they have been trying to get that changed for years because they obviously are not the same machine and it causes these kinds of problems. That's why I said we might have to get a letter of medical necessity. Insurance companies have WAAAYYYY too much control over the quality of an individual's health care! And it's not even an HMO! HMO's are even worse!

Yeah....I misread your post. Didn't see that part about how old the machine was. But I would keep fighting it with your doctors help.

[SleepingBetty]

I completely agree here. I had the same problem battling for a month with my old DME in getting my BiPAP switched out for an Auto BiPAP. The DME kept claiming that my Sleep Study did not warrant switching to an Auto. I even called my insurance company and spoke to them about switching...Insurance company said they don't really care what machine I use and they only have one code for a CPAP machine - as long as my doctor writes a RX. Finally my Sleep Doctor got pissed off and personally called the DME and reminded them that SHE was the DOCTOR and THEY were to MEDICAL SUPPLIER and to submit my new RX to my Insurance company. My Auto BiPAP was miraculously approved my machine in an hour and shipped it that same day.

CALL YOUR INSURANCE COMPANY.....do not take your DME word for anything.

Hi, Kenwood! First of all, I am truly sorry that you or anyone else has these kinds of problems with their DME's. Secondly, see the reply above to Hose_Head. It's that ONE code for a CPAP machine that is a large part of the problem... at least with our insurance. As far as they are concerned, it's one and the same machine and they don't seem to care that the doctor has written a new Rx for an AUTO machine. The DME even said they have been trying to get that changed for years because they obviously are not the same machine and it causes these kinds of problems. That's why I said we might have to get a letter of medical necessity. Insurance companies have WAAAYYYY too much control over the quality of an individual's health care! And it's not even an HMO! HMO's are even worse!

Yeah....I misread your post. Didn't see that part about how old the machine was. But I would keep fighting it with your doctors help.

Oh, we will, Kenwood! I might have to write the letter and get the doctor to sign it!

[archangle]

2) ARGH! Why the fark don't they tell you this stuff when you get a machine?!?! I can understand not giving out the keys to the clinical menu, but why should I not know how to see a report?!?!

There's a reason we call them the "medical Mafia." Picture a couple of stereotypical beefy goons in cheap suits saying "We don't wants you stickin your nose into our business, capice?"

[Stormynights]

I don't understand why these machines are even being made. I read that the machines were the same inside just different firmware. If that is true then the cost of making the machines would be the same. The machines that are auto for only a set time then are cpap that is more technology so why not just make the apap to begin with. It just doesn't make sense to me at all. Who is to blame? Maybe the manufacturer?

[mgaggie]

I don't understand why these machines are even being made. I read that the machines were the same inside just different firmware. If that is true then the cost of making the machines would be the same. The machines that are auto for only a set time then are cpap that is more technology so why not just make the apap to begin with. It just doesn't make sense to me at all. Who is to blame? Maybe the manufacturer?

Because they can make more money. Here in Aus my machine costs $1000, and the auto costs $1700.

[Hose_Head]

Good for you, VikingGnome! I hope they were successful in getting the brick exchanged! Ironically, rather than the DME, it's our insurance that is stopping my husband from getting something other than the brick he has had for years. He is having terrible mouth leaks with the old machine since increasing the pressure. I had my hands full and seriously thought about dropping yesterday as I was taking it in to the DME so he could get compliance data off of it! Wish I had! Previously, there was a gasket that was leaking, but the DME had what was needed to fix that. It was no wonder my husband had been feeling tired for a while now. He was also apparently needing increased pressure, but he is having difficulty exhaling against that increase. He went back to the loner machine from the DME, which is what he used to figure out the pressure increase, to see if that made a difference ... and it did. He got the Rx from the doctor for an APAP and the DME submitted a letter to the insurance company, telling them the doc had prescribed the APAP and that my husband was doing better on it than on the old brick. Didn't work... the DME called me today and had gotten a denial from the insurance, saying that there was no evidence my husband's machine was broken or that it couldn't be repaired. Ugh!

So, our plan is to back the pressure off on the old machine and see how he does since he hadn't used it at the old pressure with the new gasket, then gradually increase it. He has done really well with CPAP for 13 years without having A-Flex or anything like that, so it shouldn't really be that much of a problem, right? Anyway, we are kind of flying blind here, but if he can't adjust to the pressure, then the next step may be a letter of medical necessity from the doctor. Of course, that old machine may just bite the dust in the mean time!

I've quoted your entire post, and have highlighted in red the part of it that I'd like to address:

Odds are that your DME never submitted anything to your insurance, or if they did, they are lying about the response that they received. The response you got ("... no evidence my husband's machine was broken or that it couldn't be repaired") is a complete non-sequitur. It looks to me as though the DME simply doesn't want to supply the apap, despite doctor's orders that they do so.

My advice would be to start asking your DME some very pointed questions and demand clear answers to them. A call to your insurance company would be a good first start.

Hi, Hose_Head! Thanks for your comments. I'm not really following you, though. Why wouldn't the DME want to sell a new machine, APAP or otherwise? I don't think he even sells any machines that aren't fully data capable! He recommended an APAP for me and I got exactly what he said he was going to give me, a PR S1 560. He could have given me some line about not needing an APAP or data capable machine once I had been through the sleep study, but he didn't. He also could have not told me about this forum, but he did! And I'm grateful!

Perhaps you need to reread the part of my post before the part you put in red! My husband has been on CPAP for nearly 13 years. He's always had a brick and actually adapted quite well in the beginning. He's on his second machine which is now about 7-8 years old. He got it shortly after changing jobs where he was going to be traveling quite a bit and he wanted something more portable than the one he had previously, which at that point, was around 5 years old. We ran into the same problem with the insurance then. The DME (different DME, same insurance) suddenly discovered a problem with the old machine which was not fixable. Voila! My husband had a new machine, albeit another brick! But, we didn't know any better back then. However, it has served him well until fairly recently when I began to notice more and more snoring. He also was complaining of being tired in the afternoons. Something was obviously wrong.

I talked to the DME about it and he suggested an auto CPAP trial for my husband to see if his pressure needed to be adjusted. He never charged for the use of the machine, but he could have! He did charge for me when I did it, but then he let me use the machine for a couple of months until I got through the necessary sleep studies so that insurance would pay for the machine. The fee for the auto trial will go against what I owe him for my equipment, though, so it's all good. So, my husband'a auto trial indicated that his pressure needed to be adjusted. We did that, but also got a Rx from the doc for a new machine, mask, etc. which the DME has on file. My husband thought his machine was leaking, so I took it in and the DME checked it. Sure enough, there was a gasket that was totally worn out. Unfortunately, he had the necessary parts to replace it! The pressure is off just a bit, but that is something that could be worked around.

The problem is our insurance is just the opposite of Medicare! While Medicare apparently hands out stuff when you don't even need it, our insurance says they'll only replace the machine if it's broken. That's the same problem I mentioned above that we ran into when he got his current machine. The DME even suggested we switch insurance companies, but even if we did, that's not possible until sometime in the fall and won't go into effect until January 1. So, I have no reason to believe that our DME didn't submit the letter. He read me what he had written up to the point that I took my husband's machine in so he could get the data off of it to include with the letter. He actually loses by not submitting it and getting to sell a new machine. How is that a non-sequitur?

After typing a long-winded response, and then reading the follow-on posts that were posted since your reply, I see that you seem to have a handle on what may be going on here. However, be careful that your DME has not changed tactics: good service in the past is not a guarantee that they continue to provide good service today. If you haven't already done so, I'd ask questions of your insurance company and make sure that you hear the responses directly from them.

Even so, it may be an exercise similar to banging your head against the wall and as other's have recommended, bricks do have a habit of taking nasty falls off the dresser!

[Janknitz]

Ditto what was said above. If your DME claims that the insurance company denied the new machine, ASK TO SEE THE WRITTEN DENIAL. I'll bet you a doughnut they can't produce it.

Meanwhile, contact your insurance company to confirm if they denied the machine or not. You always have appeal rights.

[Hose_Head]

Ditto what was said above. If your DME claims that the insurance company denied the new machine, ASK TO SEE THE WRITTEN DENIAL. I'll bet you a doughnut they can't produce it.

Meanwhile, contact your insurance company to confirm if they denied the machine or not. You always have appeal rights.

To be fair to Janknitz, her post quoted herein seems to have been in response to my previous post, which I have subsequently heavily edited. I'll let her decide whether she wishes to change her "ditto".

I apologize for the confusion caused by editing of my post.