Newly Diagnosed

[mightybhwk]

Hi all,

I just got a message from the doctor telling me that they are going to write a prescription for a cpap machine. After reading through these forums I would like to get the S9 autoset, H5i humidifier and the other recommended accessories. Before I call the doctor back, how do I tell him what I want and does he write the prescription for that? Or do I go to the DME and tell them what I want? I read here that people sometimes have issues with DME's.

I have Cigna PPO and I believe it covers 80%. Does anyone know what is typical out of pocket expenses? Any issues dealing with Cigna?

I don't want to rent the machine. Do I need to tell the doctor this? A guy at work lost his last job and since he was renting he lost his machine.

Sorry for all the questions but I just want to make sure I get a good machine from the start.

Thanks,
Randy

[Xney]

Have you had a sleep study for titration?

If not, your prescription will probably be for an auto machine with a pretty wide open setting. You'll want to make sure your prescription is for a machine with data, or specifically says full data. Make sure the machine is something one of the current generation data-capable machines and not one of the older ones which have proprietary data methods like the S8 series or respironics M series. (They're fine machines but getting the data off of them is a PITA)

If you have that wide auto prescription, it'll probably be something like 4-15 or 4-20. Talk to your doctor ahead of time and ask him if you can narrow the range down after going over the numbers with him or something. I think it would be a bit uncomfortable to have such a wide range. Like if you check your data on sleepyhead and see your machine is usually at 7-10, then you would want to dial your range to something like 6-12. Some doctors are okay with this, some doctors will treat you like are trying to acquire leprosy.

Some people like the machine wide open, it just depends.

A baseline titration study split night (half without PAP, half with it) would be a good idea too if your insurance covers it. They suck, but it's the only way to get numbers before treatment if you haven't had it. Our PAP machines only estimate events based on air flow - a sleep study can see the awakenings.

[Xney]

Oh, very important: make sure your prescription lets you choose your mask. It's the most important part of xPAP treatment, to find a mask you like and fits and is comfortable. You want a DME which lets you return them for a different one in 30 days if it's not the right one.

[KEQ5]

Mine started wide-open at 4-20.

After a week or two of looking at my data in Sleepyhead, I tightened that up to 7-16. The 7 is because that was what looked like the minimum pressure that the machine liked to use most nights. The 16 was because I was getting aerophagia and mask leaks above that point (and I rarely go that high anyway on the graphs). Plus, the mask-fit feature on the S9 works by running the blower at your maximum prescribed pressure and I couldn't get the mask to fit properly and not leak at 20.

Raised the minimum to 9 over the past 2-3 weeks because I was still seeing obstructive apneas. Left the upper end alone because the machine never goes there, so it doesn't matter.

Make sure the doctor writes "S9 Autoset w/ humidifer and climateline" on the prescription along with the "DAW" box. Avoid any Resmed machines with the word "Escape" in the name. If your doctor does not prescribe a full-data machine, then you will have to arm-twist the DME into giving you a full-data machine and not the less expensive 'brick' that only gives you compliance (hours of use) data.

Sign nothing and be willing to walk out if they try to force a non-data machine on you.

[Sheriff Buford]

I have a Cigna PPO, and they are all different. Call them and ask them about your coverage. You are dealing with "Durable Medical Supplies". If you have an on-line account, you can look it up there too. In support of the others, get the doctor to prescribe a Resmed S9 Autoset. Let the doctors set your numbers. Get settled in and educate yourself before tinkering with your numbers. Do be afraid to use the cpap mode if you are more comfortable with that type of therapy. Your first goal should be:
1) educate yourself. Pour over this website.
2) find a mask that is comfortable and doesn't leak. Masks are like shoes. There are a bunch of em' out there and what I like, others may not. Make sure your DME (the place that gives you your equipment) allows you to return a mask within 30 days. Mask shopping is normal. I went thru a half a dozen before finding mine. It has to be comfortable because you will be wearing it all night (one third of your life). If it leaks, then you are not getting the full benefit of your therapy.
3) Work all your issues here. We are here to help you thru your journey and this may be hard to believe, but you can help "us" or someone else stay on theirs.

Sheriff

[zoocrewphoto]

Your insurance will determine whether you rent to own or buy outright. Mine rented for 2 months, and once my compliance was proven, they converted it to a sale. So, it is totally mine now. They just want us to prove that we will actually use the machine before the pay the full amount. Some insurance companies will buy it outright at the beginning. And some go for 13 months or so, and then it is yours. This is for the main blower piece. The humidifier, masks, hose, etc are purchases, so those are a done deal.

The most important thing is to make sure you get a machine with data capability so that you can fine tune your pressure needs as not everybody gets it perfect at the beginning. And your needs may change over the years. Always good to be able to check on things if you aren't feeling it is working well.

[mightybhwk]

Thanks everyone for your help! I am going to call the doctor and tell him that I want the list below.

S9 AutoSet™ CPAP Machine
S9™ Series H5i™ Heated Humidifier with Climate Control
ClimateLine™ Tubing for S9™ and H5i™ Climate Control System
Dishwasher Safe Water Chamber for H5i™ Heated Humidifier

I priced it out on cpap.com and the total came up to $1135 (without a mask). If my insurance pays 80%, would I get charged 2-3 hundred? If the DME tries to charge me more should I look at buying online? Anyone have experience with getting reinbursed?

I am so glad I found this forum! If I didn't, I would of accepted anything the DME would of giving me.

[mayondair]

Don't expect DME prices to be the same as online prices, they are typically a lot more. Call your ins co and find out if they will reimburse for an online purchase, and at what rate. It may be different rate than the DME they contract with. While you are at it, check if they pay by code EO601 for any machine, so you don't get hit with an up charge that you don't need to pay. Call your ins co, DMEs are not always up on every plan, or honest either. Get everything in writing!

[mightybhwk]

Well I called to doctor's office and they said they are waiting on Cigna to approve it. She went ahead a put the S9 autoset request on the presciption.

What is the next set in this process?

Does the DME call me? Or do I have to go and pick up the prescription and take it to a DME? I believe she said she was going to try to get SleepRX?

[Sheriff Buford]

Well I called to doctor's office and they said they are waiting on Cigna to approve it. She went ahead a put the S9 autoset request on the presciption.

What is the next set in this process?

Does the DME call me? Or do I have to go and pick up the prescription and take it to a DME? I believe she said she was going to try to get SleepRX?

Most times, if you wait, it may never happen. Greas the wheel. Follow up. Be sure you have a prescription for a "mask of patients choice". Verify that you can return the mask within 30 days if the mask doesn't work out.

Sheriff

[Pugsy]

You might want to read this.
http://maskarrayed.wordpress.com/what-y ... me-part-i/

[JoeIndy]

I priced it out on cpap.com and the total came up to $1135 (without a mask). If my insurance pays 80%, would I get charged 2-3 hundred? If the DME tries to charge me more should I look at buying online? Anyone have experience with getting reinbursed?

I have Cigna, and a 90/10 insurance coverage. They bought my Respironics Series 60 outright with no compliance requirement. The discounted price was $695, and so I paid $69.55 for it. Add in the humidifier, mask, filters, etc. In the end I was out a total of $108.04. It took them (Carecentrix does DME insurance for Cigna. Home Health Depot is my DME) about 6 weeks before they got around to sending me a bill.

You'll have to check your insurance to see what they'd cover if you bought it yourself. Odds are, it wouldn't be 80%, it'd be the "out of network" rate -- and might have a different deductible requirement as well.

When I need supplies, I call up my local HHD office, give them my name and tell them I what I need. It arrives at my door two days later with no shipping cost. Then I get a bill for $3 or so a few weeks later.

[mightybhwk]

Well I called to doctor's office and they said they are waiting on Cigna to approve it. She went ahead a put the S9 autoset request on the presciption.

What is the next set in this process?

Does the DME call me? Or do I have to go and pick up the prescription and take it to a DME? I believe she said she was going to try to get SleepRX?

Most times, if you wait, it may never happen. Greas the wheel. Follow up. Be sure you have a prescription for a "mask of patients choice". Verify that you can return the mask within 30 days if the mask doesn't work out.

Sheriff

Good to know. BTW, I'm a mouth breather when I sleep and I suspect that I would need one that goes over my mouth and nose.? Any recommendations to try out for my first one?

You might want to read this.
http://maskarrayed.wordpress.com/what-y ... me-part-i/

Yes I did read this. Thank you for posting.

I priced it out on cpap.com and the total came up to $1135 (without a mask). If my insurance pays 80%, would I get charged 2-3 hundred? If the DME tries to charge me more should I look at buying online? Anyone have experience with getting reinbursed?

I have Cigna, and a 90/10 insurance coverage. They bought my Respironics Series 60 outright with no compliance requirement. The discounted price was $695, and so I paid $69.55 for it. Add in the humidifier, mask, filters, etc. In the end I was out a total of $108.04. It took them (Carecentrix does DME insurance for Cigna. Home Health Depot is my DME) about 6 weeks before they got around to sending me a bill.

You'll have to check your insurance to see what they'd cover if you bought it yourself. Odds are, it wouldn't be 80%, it'd be the "out of network" rate -- and might have a different deductible requirement as well.

When I need supplies, I call up my local HHD office, give them my name and tell them I what I need. It arrives at my door two days later with no shipping cost. Then I get a bill for $3 or so a few weeks later.

Looking into it, I think that it is 90/10 for DME. SleepRX is suppose to call me today and talk about the equipment. I'll make sure I ask them if I will get my equipment with no compliance requirement.

How often do you go through supplies? What do you need to change out?