Doc will write my RX as I want but what about...

[macsnjets]

I passed my at home sleep test with the last part being if a cpap machine will work for my severe apnea. The report indicates a pressure of 17 and recommends a cpap machine with humidifier and heated line. I really really want the Resmed S9 autoset with H5i and climate tubing. My doc has agreed to write that specific model on my prescription and include "Dispense as written, no substitutions" but the participating DME says once they receive the prescription they will need my Insurance to authorize it. Even if my Doc says dispense as written is it possible for the Insurance company (Aetna) to say no to that specific machine? Wll my Doc have to justify the Autoset machine and how can she go about it if that's the case? I know the S9 Autoset is better for comfort and good if I plan on losing weight but what will guarantee that I get that machine? Any advice on this?

Thanks in advance
Macsnjets

[Pugsy]

The billing code for the AutoSet is the same billing code as for the straight cpap machine.
You can call your insurance company and ask if they pay by billing code or actual model name.
The billing code for cpap/apap machine is E 0601.
Most insurance companies pay by billing code...even Medicare.

You need to check with your insurance company directly though...don't rely on what the DME says.
It's unlikely that the insurance company even cares which model as long as it is an E 0601 machine.
It isn't until you get to the bilevel pressure machines that the billing code changes.

A brick non data machine and the S9 AutoSet have the exact same billing code. DMEs like to dispense the brick because profit margin is greater.

[macsnjets]

That's right, I remember you told me about the E0601 code in a different post and my insurance company does go by the codes. The DME says it will take approx 48 hours to authorize the RX by my insurance co. but safe to say I shouldn't worry about the model as long as they pay by code?

Wish me luck
Thanks

Oh yeah, since my sleep study report says 17 cm of press for a straight cpap, what should my doc write on the RX for an initial range?

[chunkyfrog]

Considering the relatively small cost difference between the lowest Escape and the Autoset,
The DME's seem to be willing to sell your health off for about four pieces of silver. Cheap at any price.

[Pugsy]

Oh yeah, since my sleep study report says 17 cm of press for a straight cpap, what should my doc write on the RX for an initial range?

Don't know if the 17 was a worst case scenario or a minimum of even if it was doing a good job.
You will want the max at 20....I think minimum at 10 or 12 and start from there.
so 10 or 12 minimum and 20 maximum. See what the reports show. May or may not need more minimum.
For sure you will need much more than the 4 default minimum.

[archangle]

If the doctor writes it with a pressure range specified, it's much harder for the DME to try to not give you an AutoSet.

If the doc wants 17, he could specify 17-20 and, in theory, the machine won't go above 17 unless you need it. Something like 15-20 would make even more sense. Monitor your progress, and if the machine doesn't find the "right" pressure, it's easy to change, or even set it to 17 manual pressure later.

Be careful the DME doesn't try to stick you with an Escape Auto. That one is very lacking in data.

Also, there is no S9 Auto. It's AutoSet. If you say "S9 Auto," they may try to give you an Escape Auto.