How frequently does insurance allow mask replacement

[danmid]

just curious, new to this whole CPAP thing....I asked Blue Cross how often they allow for replacement of the mask gasket and they simply would not tell me if there was a minimum length of time I had to wait until they would cover a replacement. They said for gaskets, masks, hoses, etc.. I would have to go to my DME provider and then they would decide afterwards if it was an eligable item.

Can anyone tell from experience about how often the insurance companies usually allow without making a big deal out of replacing stuff?

[gasp]

Short answer:
I was told the entire headgear and mask is completely replaced every six months.

Long answer includes everything and masks:
My insurance company doesn't care how often I get any durable medical supplies, as long as I don't exceed my $5,000 cap per year. I use supplies as follows and the * indicates this is my DME insurance guideline period:
-Hose: 1 new every six months*
-Grey filter: 1 new every six months*
-Fine filter: 1 new every month*
-Humidifier chamber: 1 new every six months*
-Headgear: 1 new every six months*
-Mask (nasal pillows) 1 new every month
(DME says insurance guideline allows for one every two weeks)
-Mask (cushion) 1 new every six months - I use only when asthma flares up and have to use it.
(DME says insurance guideline allows for one every two weeks)

You may find this link helpful:
viewtopic.php?f=1&t=34340&p=293641&hili ... ks#p293641

[6PtStar]

My BCBS uses the same schedule as medicare.

HCPCS Code Description Allowed Replacement Frequency
A7030NU Full Face Mask 1 every 90 days
A7031NU Full Face Cushion 1 every 30 days
A7034NU Nasal Mask 1 every 90 days
A7045 Exhalation Port with or without Whisper Swive Span Not Yet Released By Medicare
A7032NU Nasal Mask Cushion 2 every 30 days
A7044NU Oracle 1 every 90 days
A7033NU Nasal Pillows 2 pairs every 30 days
A7035NU Headgear 1 every 180 days
A7036NU Chinstrap 1 every 180 days
A7037NU Tubing 1 every 30 days
A7039NU Non-Disposable Filters 1 every 180 days
A7038NU Disposable Filters 2 every 30 days
A7046 Humidifer Chamber Span Not Yet Released by Medicare
E0601NU CPAP Varies Greatly - Call For More Information
E0470NU BiPAP Varies Greatly - Call For More Information
E0562NU Heated Humidifier Varies Greatly - Call For More Information
E0561NU Passover Humidifier Varies Greatly - Call For More Information

One thing I did find is that a mask can be replaced every 90 days but the headgear can only be replaced every 180 days. Most DME's won't sell just the mask so in order to get the complete package you are limited to 1 every 180 days (6 months).

Jerry

[yorkiemum01]

Well...can only quote 'my insurance allowable' .
Semi-annually my mask as a whole, hose, and humidifier chamber.
Quarterly my filters, and mask 'gasket'. I began therapy in Feb of this
year and I still have lots of life left on my original issue mask, but did
order one as an alternate. To my knowledge, the machine is rented until
the 'DME allowable purchase price' is met, and a new machine is covered
after 4 years. The rental fee the insurance pays is far more than one would
pay buying outright on cpapaction.com, so weigh your options if you pay
out of pocket (deductible) as I do. On my particular insurance plan, the
initial $2500.00 is applicable under deductible before being paid out.
I've certainly been 'educated' in my health insurance plan this year. Ouch.

[danmid]

Thanks everyone....I am going to try to go in 2 months for more nasal pillows and see what happens. I should be able to hold out for 6 months or so on the rest. If I have to pay out of pocket, at least the pillows aren't bank breakers...

[shortbus]

I have First Priority Health which is owned by BCBS and they told me there is no replacement policy. In other words you get one for life the rest you buy. Durable goods they only buy it once. I have to buy everything on my own and if my bipap breaks I have to pay for a new one.

[Dennisla]

My BCBS uses the same schedule as medicare.

HCPCS Code Description Allowed Replacement Frequency
A7030NU Full Face Mask 1 every 90 days
A7031NU Full Face Cushion 1 every 30 days
A7034NU Nasal Mask 1 every 90 days
A7045 Exhalation Port with or without Whisper Swive Span Not Yet Released By Medicare
A7032NU Nasal Mask Cushion 2 every 30 days
A7044NU Oracle 1 every 90 days
A7033NU Nasal Pillows 2 pairs every 30 days
A7035NU Headgear 1 every 180 days
A7036NU Chinstrap 1 every 180 days
A7037NU Tubing 1 every 30 days
A7039NU Non-Disposable Filters 1 every 180 days
A7038NU Disposable Filters 2 every 30 days
A7046 Humidifer Chamber Span Not Yet Released by Medicare
E0601NU CPAP Varies Greatly - Call For More Information
E0470NU BiPAP Varies Greatly - Call For More Information
E0562NU Heated Humidifier Varies Greatly - Call For More Information
E0561NU Passover Humidifier Varies Greatly - Call For More Information

One thing I did find is that a mask can be replaced every 90 days but the headgear can only be replaced every 180 days. Most DME's won't sell just the mask so in order to get the complete package you are limited to 1 every 180 days (6 months).

Jerry

I have BCBS. So based on the above I called my DME to see if I could get a replacement Nasal Pillow for my Swift LT which I Originally got on June 27.
They told me 90 days for the Swift LT replacement. I said I just want the Nasal Pillow not the entire headset and all.
Turns out they do not carry replacement parts. Only the entire mask set. So I cannot get only Nasal Pillows from them.
I might call BCBS and check on the "2 pairs every 30 days" and if so I'll ask how am I to go about getting them if my DME does not carry them.
Maybe they will cover 80% of on line purchases? Worse case I am entitled to a complete Swift LT replacement on the 27 I guess.

-Dennis

[DannyPh]

After reading all the Posts here I am confused as Hell. I have Medicare and BC/BS and my DME ( American Home Patient ) has Replaced my Complete Mask w/headgear ( Swift II Nasal Pillows ) along with Hose and Filters and extra Pillows every three Months. I also got another Chin Strap after three months. I have been on CPAp for almost a Year now and haven't had one bit of Resustance from either BC/BS or Medicare on replacements every three months. Seems to me like some of You are just expierencing " Tight Ass DME's ". Best of luck to you all.

[OutaSync]

I also have BC/BS and when I inquired as to coverage, they wrote to me that I could get up to $2000 a year in equipment. They did not provide any schedule with that.

Bev

[Twilightcat]

HI,

After reading these posts, I'm a bit confused. Generally, do insurance companies require periodic checkups by the sleep doctor in order to pay for equipment ?

I've been on CPAP a little over one year, and after my one month checkup with the sleep doctor I never returned for another checkup, because I felt I had learned so much thanks to this forum. I assumed I would always be paying out-of-pocket for equipment from CPAP.com. I recall phoning the insurance company and hearing that I had a high deductible. Also, my dme doesn't carry my favorite mask, the headrest.

Do you think that after five years when I need a new machine I could return to the dme, order one and ask insurance to pay for it, even without annual checkups? Any thoughts on this?

Thank you,
Twilightcat

[Vader]

just curious, new to this whole CPAP thing....I asked Blue Cross how often they allow for replacement of the mask gasket and they simply would not tell me if there was a minimum length of time I had to wait until they would cover a replacement. They said for gaskets, masks, hoses, etc.. I would have to go to my DME provider and then they would decide afterwards if it was an eligable item.

Can anyone tell from experience about how often the insurance companies usually allow without making a big deal out of replacing stuff?

I have BC/BS and I'm allowed a COMPLETE mask change every 90 days. I have a cap of $2000 per year in DME supplies.

As a side note, ever since I stopped using harsh soaps like Dawn liquid to clean my mask,(which of course we know we're not supposed to use) the silicone seal on my Quattro lasts(seals) MUCH longer. Also, it doesn't get that white film type discoloration anymore either.

[RipVW]

All of this varies depending on insurance provider policies, but my BCBS of North Carolina began just last year requiring my DME to provide them with an annual compliance report. My DME sent me the blank report form upon which I had to record my total hours of compliance during the past 12 months--pretty silly, in my view, since one could put in any numbers there. Surprised that they do not require a machine reading of hours of use to verify this (perhaps some insurance companies do require such verification?).

[gasp]

I have First Priority Health which is owned by BCBS and they told me there is no replacement policy. In other words you get one for life the rest you buy. Durable goods they only buy it once. I have to buy everything on my own and if my bipap breaks I have to pay for a new one.

That's sad. I hope they get very little money in premiums to offset they're lack of coverage!

[Insomniyak]

I have Anthem which is the same as BCBS,

new mask and headgear every 6 mos.
new mask every 3 but if before 6 months, I would have to for headgear if needed
new hose every 6
new grey filter every 6
new fine filter every month (they usu. come in 6 pack tho so if the DME is good, they will advance)
new humidifier chamber every 6
gel/seal/ cushion every month if necessary

I am using a Resmed Mirage Micro and is almost too small, although I like the profile. My DME is letting me borrow an Mirage Activa until I can buy one (this is an opened item) so I switch off every few nights.

[DreamDiver]

Turns out they do not carry replacement parts. Only the entire mask set. So I cannot get only Nasal Pillows from them.
...
-Dennis

My Ex-DME sold me the entire package at the per-part cost - that's how it printed out - rather than the package cost, but also does not sell parts separately. I to would have to buy a whole new mask. What's wrong with this picture?