AutoPAP machine: What should my doctor's prescription say?

[JerryL]

Last Spring, I got a CPAP machine, but then I discovered that I had been sold a machine that was constant-pressure and displayed no data at all. (For details, see this thread.)

The folks on this forum gave a lot of good advice, but I just felt stupid going back to my doctor and saying "You wrote the wrong prescription". So like many CPAP owners I put it off... and put it off... and did nothing.

Now it's 8 months later, and my sleep is still bad. So I want to go back to my doctor and say, nicely, "It is essential that my xPAP machine be able to display data on each night's sleep, and I strongly prefer that it be an AutoPAP machine." Hopefully he will agree. If he does, what should his prescription say? Last time the text of the prescription was somewhat cryptic to me, and I'd like to be able to look at the prescription and know whether it has the key words needed.

(Am I correct that every AutoPAP machine records full data? In other words, if he writes a prescription for AutoPAP, I don't have to worry about the data issue?)

[Pugsy]

(Am I correct that every AutoPAP machine records full data? In other words, if he writes a prescription for AutoPAP, I don't have to worry about the data issue?)

Used to be that was the case but ResMed has a model line called "AirStart" and they are all bricks...including the apap model.
Now the ResMed AirSense AutoSet which is the apap capable model is full data.

Best thing to have him say is a range of pressures....like 6 to 12 or whatever...AND a special mention to "full efficacy data"...then no one can try to sneak in a brick of some sort.

Example
CPAP/APAP with heated humidifier
pressure 6 minimum and whatever maximum
Full efficacy data available
Mask of patient's choice

[chunkyfrog]

Not every one.
Avoid the Restart machines, even if "auto".
There are others.

[greatunclebill]

pretty sure insurance is not going to pay for a new machine no matter what the doctor writes after only 8 months.

[JerryL]

pretty sure insurance is not going to pay for a new machine no matter what the doctor writes after only 8 months.

What if I'm willing to pay for it myself? I'm not rich, but there are good APAP machines for $900 or less. I legally need the prescription, but don't legally need insurance, right?

However, I am on Medi-Cal (California's version of Medicaid) -- so maybe they have rules against their doctors writing prescriptions that their own plan doesn't cover?

[Jas_williams]

Look at secondwindcpap.com and buy yourself a lightly used Resmed autoset 10 $479 we can help you set it up a copy of your existing prescription should be suitable

[Pugsy]

I legally need the prescription, but don't legally need insurance, right?

Legally need the RX for what reason? Why do you think that you need a special RX from a legal viewpoint?

It's not illegal for someone to buy a machine and use it and not posses an official script. No laws are broken if I don't have a RX and go to craigslist and buy something someone is selling and I want to use it if I buy it. They aren't breaking any laws selling it to me and I am not breaking any buying it and using it.

The original RX for CPAP covers that from a legal standpoint because an apap machine is a cpap machine with additional functions available....it's still classified as a cpap machine though in terms of insurance.
It's the equipment suppliers choosing the cheapest equipment possible who make out like it's a big deal to have it say apap.
People should be able to tell a supplier that they want the apap capable machine ...and get it and the DME can still fulfill the RX requirements as to settings even if the settings written down aren't apap settings....all apaps have cpap mode available.
DMEs could just dispense the apap machine set to cpap mode...pretty simple and a lot of supplier will do just that. Dispense apaps without a big fuss and quite happy with the profit they make...yeah, it's a little less than what they would make if they dispensed bricks...but they actually put patient needs over their profit margin. Those are the good DMEs.

The HCPCS billing code for your brick is E0601..the is what insurance uses for paying...and the HCPCS billing code for the apap version of your machine is guess what...the same E0601 billing code.
Insurance pays your supplier the same amount no what machine model...they don't care about brick vs full data or cpap vs apap....and they don't care about brand either.

I doubt your Medi Cal cares about anything but the HCPCS billing code number....but when Medicaid type of insurance is involved typically the reimbursement rates for anything are really low....lower than what normal insurance like Medicare might pay for something. This is where patients are often told "your insurance only pays for this cheaper model"...not necessarily true since insurance doesn't care about models or brands...but DMEs who value profit margin over patient care will often blame the insurance for their greed.
MediCal is sort of off in its own little category when it comes to state Medicaid kind of insurance...they might actually state something in the wording about which machine they will pay for. I know that I would ask for written proof if a DME fed me that line though.

You most likely won't get MediCal to cover a new machine for you without a huge fight and the doctor would have to really run interference for you and do a lot more than a specially worded RX...and you would need some back up from a supplier who wouldn't care about profit margin. They already got whatever they are going to get from your insurance.
Now if you had special medical needs that the current machine couldn't meet for some reason...like you needed a totally different kind of machine there might be some hope but just having data available probably won't cut it unless your doctor can say that it's a critical medical need that he see the data.

My suggestion...go get a gently used DreamStation Auto CPAP model DSX500 and stick it on your existing humidifier...and do your own thing.
Online sellers like cpap.com will require a copy of the RX but a CPAP RX will allow them to sell you an APAP machine.
I would look at secondwindcpap.com.....a RX for CPAP will cover them legally for selling you an APAP.....because remember an apap is a cpap with just an additional mode of operation available.

Check out Amazon also...no one will ask for a copy of the RX...because no one cares when insurance isn't involved.

[Okie bipap]

Check your local Craig's list and face book marketplace ads. I found a very slightly used machine on marketplace for $225. If you do use either of these, make sure you meet some place safe to conduct your transactions. Many local police and sheriff offices offer safe places to conduct such transactions.

[JerryL]

I legally need the prescription, but don't legally need insurance, right?

Legally need the RX for what reason? Why do you think that you need a special RX from a legal viewpoint?

It's not illegal for someone to buy a machine and use it and not posses an official script....

Thanks for clarifying this!

Then let me ask you a related question. When I purchased my constant-pressure CPAP machine, the DME supplier looked at my doctor's prescription, and then set the pressure level. My understanding was that once he set this, I couldn't change it. Perhaps the medical supplier or the doctor has some secret passcode that would let them reprogram this machine if necessary, but I (even though I am the machine's "owner") do not have the ability to change the pressure to something else.

Is that correct?

What about an AutoPAP machine? When an AutoPAP machine is purchased through standard medical insurance and a traditional DME supplier, do they program it with certain settings that the new owner cannot override? For example, if the prescription says "Needs variable pressure between 6cm and 15cm," would they set 15cm as the max pressure -- so even though the machine is physically capable of going to higher pressures, the user cannot do anything to increase pressure over 15cm?

If the answer is yes, then my next question is this: Suppose I were to buy an AutoPAP machine through a non-traditional forum (such as SecondWind or even a random internet site). Would this machine be fully programmable by me? In other words, it wouldn't have any programming that I couldn't override?

Apologies if this question makes no sense... I am so very tired.

[Pugsy]

When I purchased my constant-pressure CPAP machine, the DME supplier looked at my doctor's prescription, and then set the pressure level. My understanding was that once he set this, I couldn't change it. Perhaps the medical supplier or the doctor has some secret passcode that would let them reprogram this machine if necessary, but I (even though I am the machine's "owner") do not have the ability to change the pressure to something else.

Is that correct?

DMEs can't change a doctor's prescription without the doctor's okay.....very much like a pharmacist can't change the RX for a certain medication.

BUT there are no laws affecting your changing anything on your machine or deciding if you want to take those pills once a day instead of twice a day..
So DMEs...they have some rules they have to follow...but those same rules don't apply to you.

You really need to read this entire page.
https://www.apneaboard.com/adjust-cpap- ... tup-manual

It's easy to program your own machine...I have had well over a dozen I guess....and every single one I have programmed myself.
All my machines were bought privately and skipping insurance involvement at all.
Secondwind will set the machine up for you if you tell them what to set it at...but there is no reason in the world you can't do it yourself. It is super easy despite the DMEs making out like it's a national secret and someone will come to your house at 3 AM and cart you away in handcuffs....There is no cpap police out there watching anything we do.

[palerider]

I legally need the prescription, but don't legally need insurance, right?

Legally need the RX for what reason? Why do you think that you need a special RX from a legal viewpoint?

It's not illegal for someone to buy a machine and use it and not posses an official script....

Thanks for clarifying this!

Then let me ask you a related question. When I purchased my constant-pressure CPAP machine, the DME supplier looked at my doctor's prescription, and then set the pressure level. My understanding was that once he set this, I couldn't change it. Perhaps the medical supplier or the doctor has some secret passcode that would let them reprogram this machine if necessary, but I (even though I am the machine's "owner") do not have the ability to change the pressure to something else.

Is that correct?

No.

What about an AutoPAP machine? When an AutoPAP machine is purchased through standard medical insurance and a traditional DME supplier, do they program it with certain settings that the new owner cannot override? For example, if the prescription says "Needs variable pressure between 6cm and 15cm," would they set 15cm as the max pressure -- so even though the machine is physically capable of going to higher pressures, the user cannot do anything to increase pressure over 15cm?

No.