Where do I even begin

[hairfallingout]

For the name well the stress that the DME and the doctor has put me in yep hair is thinning out.

Seriously though. I have been told I need to go have a sleep study done to see if I have sleep apnea and I did the home study because clearly it was cheaper then going to there clinic from what the doctors office has said. I was told I have moderate sleep apnea. I went back to the doctors office with a family member who knows more about the apnea then me and has had a few machines over the years. I told the doctor I wanted the auto bi pap as i had tried this persons auto machine and I did not like having to breath through the auto and all against the pressure and that I tried there auto bi pap machine and it was way easier to breath. I told the doctor I wanted her to send into the insurance for the auto bi pap and said I ONLY wanted to be sent in for the auto bi pap and NOT auto. This person sent to my insurance for auto or auto bi pap. I was told the insurance probably won't go for auto bi pap by the doctor and that I would need to get the auto try it out then go back to trying the auto bi pap after proving I can't sleep with the auto.

I had an appointment this week with the DME because they said I had been approved well guess what that wasn't true because the day I thought I was getting a auto bi pap in there office they said then I must have the auto first well I said no I'm not doing the auto and everyones attitude did a 180 from the time i walked in. They kept saying these are the steps you must follow because of the way the insurance company is. When I got home i called the insurance to find out that it was still processing and I hadn't been approved yet.


My question here is has anyone had a doctor send both auto and auto bi pap to insurance to be approved and did the insurance approve both or just one of the two??
Because in my eyes insurance will go with the cheaper machine which is the auto and not the auto bi pap. I'm feeling like i have been royally screwed here and almost at the point where I'm about to say the hell with it and pay out of pocket for the dang thing and get what I want. For my job I really need to get going with this machine to make sure I am getting the proper rest I need.

Thank you,
hairfallingout

[zonker]

can't answer your question, so will bump this in hopes that someone else can.

welcome aboard and good luck to you.

[hairfallingout]

Thanks, I'm thinking I can't be the only one who the doctor has sent to the insurance company for both auto or auto bi pap. I realize this a very very lucrative business and if you don't do your home work researching on forums like this you can really get burned.

[zoocrewphoto]

A lot of insurance companies require the person to fail at a cheaper machine before they will consider payment of a more expensive machine. Most people do not need a bipap, and they do cost more.

What pressure range did the doctor prescribe for you? Have you tried that with the friend's machine and using the pressure reduction options available? For example, I use a pressure range of 11-17 with a reduction of 2. My auto machine can go down by 3, but I have never felt the need to go that low. Most people, given a week or two,find that the pressure that felt really strong at the beginning really isn't that much. Within a week, I was waking up and thinking my machine had turned off because I could not feel the air flow.

If you want insurance to pay for the machine, you are stuck playing by their rules. If you don't mind paying on your own, you can buy new or used and get whatever you want.

[zonker]

Thanks, I'm thinking I can't be the only one who the doctor has sent to the insurance company for both auto or auto bi pap. I realize this a very very lucrative business and if you don't do your home work researching on forums like this you can really get burned.

you won't get much argument from people here on the doing your research bit. we aren't exactly enamored of sleep docs or insurance or durable medical equipment people.

hmmm, does that make us sound like a crabby bunch?

you'll get pretty much all the help you need, right here.

[TropicalDiver]

A few thoughts here. Background: My first machine was a ResMed S9 VAuto (that was replaced by the AIrcurve 10 VAuto). My prescription was for the bilevel only because my inital pressure need was above 20. I also needed some pressure relief (again, supported by the sleep study). My study was in a lab and was a split study (part evaluation and then working through masks and settings).

First, I actually don't blame either the DME or the insurer in this instance. The sleep study supported the need for treatment but (by definition) did not support a need for bi level. That would happen only when you are using a machine and can demonstrate the need for bi-level support. The doctor wrote the script for either so the insurer is filling with the lower cost alternative. Put simply, you have yet to demonstrate the medical need for the more expensive machine. Your wish (based on playing with what someone else has) is not sufficient in the eyes of the insurer. Even if the doctor wrote it only for bi-level, odds are the insurer would balk as the medical records/testing would not support that determination. You need a demonstrated need for the more expensive device.

Second, buying yourself versus insurance. I think this depends on your tolerance for trying different things, how generous your insurance is, and how much money you spend out of pocket. I bought a low-hour used Aircurve Vauto as my back up machine from LSAT (on this board) and am very happy with it. It was an amazing deal at less than $550. That is still way more than what my out-of-pocket was for the new AirCurve (after insurance and I was already approaching my out-of-pocket max). For others, their out-of-pocket costs for the new machine are way more than what that used machine costs. So, if the $550 is not a big deal, y=or your insurance sucks, then by all means consider the used machine. (A new Vauto is around $1700).

Third, what to get/try. Personally, I would buy a machine either from Resmed (Aircurve and AirSense) or Respironics (Dreamstation). You want auto and you want full data. But saying Dreamstation does not narrow it down much -- there are many models. Same with ResMed models. I personally prefer the feel of the resmed -- it just seems to fit my breathing better (hard to explain) although the Respironics machine was also very nice.

A quick bit about bi-level and auto. Ignoring a few categories of machines, the auto function increases pressure if it begins to detect apneas. It does not do this instantly so I am not sure what "breathing through the auto" means). A bi-level machine effectively drops the pressure on exhalation -- but nowhere near zero. A non-bilevel auto typically offers some pressure relief on exhalation -- a bi-level can do more. But how much you should do will depend on how you repond to treatment. Finally, an auto machine typically benefits from tweaks -- others here can help a great deal.

Finally, how to proceed. Either don't use insurance for the unit, get the non-bilevel, or go through their hoops. You might find a bi-level more comfortable than a plain auto but we don't actually know that to be the case. And, for me, mask fit was the hugest issue I faced -- finding the righ mask for me was transformative.

In terms of units, in your shoes I would personally seek the AirSense 10 Autoset, AirSense 10 Autoset For Her (preferred choice if insurance pays), or AirCurve 10 Vauto (self pay). Avoid airstart (limited data).There are equivalent models in the Dreamstation family.

[hairfallingout]

I have asthma and I cough a lot, I had read about where the auto bi pap because its less pressure when you exhale that it is easier to deal with then the auto and tryin the auto and auto BiPAP the was the family members machine I would have to agree. I played with different setting with the auto and it was like I liked the pressure I had for breathing out yet it wasn't enough for breathing in. I deleted all the info on the card on this auto and slept with it a week which was about 2 hours each night I couldn't go longer then that, the doctor said the machine was to old and they didn't have a card reader for it so that was a bust.
I personally am to scared to buy a used machine I want new simply because the asthma and I have had to many flare ups with that so I refuse to buy use on that note.
Prescription says Max (cm H2O) ps 3-8, EPAP (cm H2O) 4-16, IPAP (cm H2O) 8-20
Theres these other numbers that say REI 20.2, OAI 9.2, CAI 1.5, Lowest Desat 83

[zoocrewphoto]

I have asthma, too. Never had a problem with the asthma and cpap.

When I have a cough (either asthma, bad cold, allergies, etc). I have to raise my starting pressure from 11 - 13. Otherwise, I start to gasp like i can't get enough air. With the higher minimum, I can get through a coughing spasm without removing the mask,and then fall asleep okay. My exhale relief is set to 2, so at 11, my exhale is 9. At 13, it is 11.

I really don't notice the pressure being uncomfortable until I get to 15 which makes my cheeks flap a little. (I use a full face mask since I mouth breathe all night and a good portion of the day).

[hairfallingout]

I find that I sleep on my stomach and side a lot so I am looking at this hybrid nasal/mouth mask. I feel like I equally breathe through my mouth and nose as I am trying to go to sleep. I'm not sure I like that nasal only mask because all the congestion I have most of the time. At this point I'm giving it till next week if I don't hear anything from this insurance i'm ordering what I want, I drive 18 wheelers for a living and I just know the next company I am trying to go with is gonna give me flap about the whole sleep apnea thing, a bunch of these companies are cracking down on drivers these day which they should if it truly helps you to get more rested.. If i can show them that yes I am using this machine it will be alot less headaches plus I truly do want to get the best rest I can get.

[ChicagoGranny]

Prescription says Max (cm H2O) ps 3-8, EPAP (cm H2O) 4-16, IPAP (cm H2O) 8-20

There's something strange about your DME story.

Those are settings for a bi-level machine (BiPAP). Regulations require that the DME fill the prescription as written. So, they can't provide you an APAP against this prescription. They must provide a BiPAP.

You need to speak with your insurance company. Tell them your doctor has prescribed a bi-level machine. The language of insurance is HCPCS codes. The code for a bi-level is E0470. Give them this code and ask them if it is approved for you and what the benefit is. (The insurance code for an APAP is E0601.)

BTW, I'm not convinced you need a bilevel machine. You're a truck driver. I am a small elderly person and am not capable of driving a semi. However, I can easily breathe out against the highest pressure an APAP can provide - 20 cm.

Good luck!

[Pugsy]

Prescription says Max (cm H2O) ps 3-8, EPAP (cm H2O) 4-16, IPAP (cm H2O) 8-20

These settings can only be fulfilled by a Resprionics Auto BiPap. A regular Auto/apap machine will not be able to deliver what the doctor ordered..
The PS min of 3 and max of 8 is what makes it something a regular auto/apap machine can't do.
The ResMed bilevel auto won't do it either...they only offer fixed PS.
PS is pressure support or the difference between inhale and exhale that you find you need/like and want.
If the doc had just said 3 PS....that leaves the door wide open for even the regular auto like the ResMed AutoSet...it will give 3 cm PS in it's EPR but with the range of PS on the RX...only the Respironics bilevels will do that.

The equipment supplier shouldn't ever alter prescriptions....now whether or not the insurance company will pay for it without supported proof of need...that's another story.

Give the supplier a chance to see if they can get the insurance company on board before going into a panic.

[Okie bipap]

I am also asthmatic, but had no problems with buying a used machine. If you are not going to use your insurance, simply purchase one that has not been used in a smoker's home, or a home with pets. The person I purchased my machine from was also asthmatic, so he didn't smoke, and did not have pets in the house. LSAT, a member of this forum often sells low hour machines. His machines are very lightly used. Another source of machines is Secondwind CPAP. They sell new, open box machines as well as lightly used machines. Most of these machines come with a warranty.

[hairfallingout]

Thanks Pugsy and chicagogranny.
I really do want insurance to pay for it. I am a bit confused on this though. When I called the insurance company a few days ago to talk to them they had said where they had received the sleep study results but they were waiting for clinical from the dme. I asked what does this mean and this lady couldn’t tell me because she just didn’t know. It almost sounded to me like maybe they wanted to hear about me using a machine yet still wasn’t authorized. I get different answers every time I call the insurance company depending who I speak to. I will say I live in Louisiana and this state is arse backwards it’s not funny. Getting anything done is at a snails pace.
I will be calling again this week for updates and what this waiting for clinical mean.

[Okie bipap]

My original prescription called for a bi-level machine. It included a statement that said the patient did not tolerate CPAP. It went through with no problems. My initial settings were higher than a CPAP could support.

[ChicagoGranny]

I really do want insurance to pay for it.

+1

I will be calling again this week for updates and what this waiting for clinical mean.

Ask to speak to a supervisor. Tell the supervisor the prescription calls for a bi-level (E0470).

I will say I live in Louisiana and this state is arse backwards it’s not funny.

When it comes to DMEs and insurance companies, you can multiply that by 50 states.