I need help with a longer shovel :-)

dragonflybeach · Post by **dragonflybeach** » Tue May 15, 2012 10:03 pm

I've twice requested an Auto machine and twice been sent a straight CPAP. The following are a few lines from an email I received.

The DME has told me:

1) based on the docs report, I only need straight CPAP not AUTO
2) my insurance will need additional documentation from my doc why I need auto versus straight CPAP
3) Auto is intended for patients with severe obstructive sleep apnea which require a pressure setting higher than 10
4) My pressure setting does not warrant an AUTO
5) The S9 Elite and F&P Novo is what is mostly used by their patients along with the Remstar M series
6) AUTO is more expensive and I may end up paying the difference since it's not approved by the payor

I've already spoken to my insurance carrier and been told that they will cover the S9 Autoset at 100%.
I'd love to hear some suggestions as to how to handle this calmly and quietly.
Thanks so much.

Julie · Post by **Julie** » Tue May 15, 2012 10:09 pm

Has your doctor written a prescription for an apap?

Have you reminded him/her that apaps can also be used as cpaps, but cpaps cannot be run as apaps?

He's the one who directs the DME about what to give you... the DME cannot do it on their own.

dragonflybeach · Post by **dragonflybeach** » Tue May 15, 2012 10:19 pm

No, the Rx does not specifically state APAP. It says pressure of 8 for CPAP treatment.
But if the S9 Elite and S9 AutoSet are billed under the same code and the autoset can be run in straight CPAP, what is the difference?

cowlypso · Post by **cowlypso** » Tue May 15, 2012 10:25 pm

The difference is that the DME is getting the same amount of money from the insurance company for both machines. But the auto machine costs them more. If they can keep you from getting an auto, they make more money.

Easiest solution is to get your doctor to write the prescription for the auto. Another easy solution is to find another DME who wants your business.

archangle · Post by **archangle** » Tue May 15, 2012 11:39 pm

Find out if there are other DMEs who are in network for your insurance.

If so, contact DME #2 and say "you get the business if you dispense the machine I want."

The DME doesn't have to give you anything more than the minimum CPAP to fill the prescription. Hopefully, you can take your business to another DME.

If your doctor is willing to write a prescription that specifies a small pressure range for instance 8-10, it might help.

LSAT · Post by **LSAT** » Wed May 16, 2012 6:16 am

dragonflybeach wrote:No, the Rx does not specifically state APAP. It says pressure of 8 for CPAP treatment.
But if the S9 Elite and S9 AutoSet are billed under the same code and the autoset can be run in straight CPAP, what is the difference?

It doesn't matter what the insurance will pay for. The DME is doing exactly what they should. Fill the prescription as written. It is the same as a pharmacist...they fill exactly what the doctor prescribes....they cannot substitute. Get your doctor to re-write the prescription.

Sheriff Buford · Post by **Sheriff Buford** » Wed May 16, 2012 6:32 am

Just wondering.... why do you want an autopap?

Sheriff

dragonflybeach · Post by **dragonflybeach** » Wed May 16, 2012 6:34 am

OK, next question. My doctor is a NP. Can she rewrite the prescription? Do I have her write auto pap? Does she need to list a pressure range? The sleep lab is 2 hours away and I don't speak the native language.

Thanks in advance for any help.

dragonflybeach · Post by **dragonflybeach** » Wed May 16, 2012 6:44 am

Sheriff Buford wrote:Just wondering.... why do you want an autopap?

I had a horrible titration study. They got my AHI down to about six but I was all sorts of panicky. The mask was leaking into my eyes. I could never get off my back without leaks. My sleep efficiency was 61% and my lowest desat was 77 for 30 seconds.

When I got home the next day, I was miserable, cranky, tired and feeling pain all over.

I'm thinking it wasn't a very successful titration study.

Pugsy · Post by **Pugsy** » Wed May 16, 2012 7:00 am

Your NP can write the RX. Any medical professional who can write scripts can do it. Even a Vet or a dentist.

The DME could fill the current script with APAP set to CPAP mode but they don't want to and there is nothing to make them do it if they don't want to. You could shop around and try to find a DME that would...because they can if they would but many dig in their heels because they don't like dispensing more expensive machines when they don't have to.

To avoid fighting about it. Get a RX that says the specific brand and model you want and a small range of pressures...like the 8 - 10 range and mark the little box for "dispense as written".

In your case you want the S9 AutoSet so have it plainly state that model along with a pressure range.
Don't let them try to sneak the Escape Auto in because it doesn't offer full data....it only offers AHI and pressure averages..nothing else..no leak..no AHI breakdown into categories.

squid13 · Post by **squid13** » Wed May 16, 2012 7:01 am

dragonflybeach wrote: The sleep lab is 2 hours away and I don't speak the native language.

Since you don't speak the language, where are you located at? It would help to know what country you are in.

Lizistired · Post by **Lizistired** » Wed May 16, 2012 7:04 am

I agree with archangel. get a copy of your script and complete reports and go DME shopping. I did and I got a autoset with a cpap script, because the script was in my hand, not the DME's.

dragonflybeach · Post by **dragonflybeach** » Wed May 16, 2012 7:14 am

squid13 wrote:
dragonflybeach wrote: The sleep lab is 2 hours away and I don't speak the native language.
Since you don't speak the language, where are you located at? It would help to know what country you are in.

I'm in Japan as a military dependent. My Rx is faxed to a Stateside DME who ships us what we need.

Pugsy · Post by **Pugsy** » Wed May 16, 2012 7:23 am

You have Tricare don't you?
I didn't realize you were in Japan and a long way from choice of suppliers. Does Tricare dictate a specific DME for you or do you have a choice?

LSAT · Post by **LSAT** » Wed May 16, 2012 7:37 am

Your DME has already given you a 'Top of the line" Resmed S9 Elite. Most people would be very happy to have a unit like that.

I need help with a longer shovel :-)

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