Do I need to break my machine? **UPDATE **

[schnertling]

I have a moral delemma and would appreciate input.

My latest sleep study shows I need to increase my pressure from 10 to 14 cm. The sleep doc wrote for a script for a NEW cpap machine which will be replacing my current M-star which is five years old and used daily.

The sleep center which dispenses the cpap machines is telling me that they will only "recalibrate" my current machine, not dispense a new one. The only way they give out new machines is if the old machine is "broken and not repairable...otherwise they repair the old one" per the insurance company (BCBS).

My doctor specifically said not to let them "recalibrate" the old one and wrote "NEW CPAP MACHINE" on the order. She said the average life span of a CPAP machine is five to seven years. Sleep center still refuses citing insurance rules.

I'm concerned that my old machine is at the end of its useful life and will need replacing soon, probably at my expense. Do I make my old machine "broken and unrepairable" or have the recalibration done and end up having to eat the cost of a new machine? The insurance company will only replace a broken machine within a short amount of time after a sleep study.

I appreciate any advice.

[chunkyfrog]

How old is the old machine? (edit--I see, 5 years--my BCBS replaces at 5 years-YMMV)
--Check with insurance--DME's don't always know (or share) what insurance covers.
--The doctor's note specifying 'medical necessity' should bear some weight.
--Try a different DME in network--these guys may be yanking your chain.
--Accidents can happen-especially with water in the tank--(pets in the house?)

[chunkyfrog]

Never mind all the above!
Tell BCBS that the DME are being difficult--let them take care of it.

[mayondair]

Or maybe just ask your doc to specify an APAP with a narrow range, no moral dilemma there and you can keep the old one for a back up

[wilsonintexas]

I would call yoru insurance and ask them directly..... my DME said I owed a "upgrade fee"...... no such thing...... They wanted to make up the loss for giving the auto that was perscribed..


If the insurance company says no it has to be re-calibrated unless it is broken.....
It would also be a real shame, if you were cleaning the machine my the sink, like they recommend, with a damp cloth and the whole thing fell in the sink full of watter.... oops it slipped as I was cleaning it..... recalibrate this one...... but unplug it first.

But not sure if it would be covered nor not........

I guess it would be a shame if it sucked in a lot of dirt... say a bag from a vacume sweaper were to break and the machine sucked it all in.... that would be a real shame....

I have a real big dog...... I will have to get the picture.....

[Pugsy]

This goes back to the fact that just because a doctor orders something it doesn't mean that the insurance company has to pay for it if they can find a way out of it. It happens all the time. I think we are going to see a lot more of the "replace only if not repairable" instead of a regular schedule like the prior 3 years for some companies and 5 years for others.

How much would you be out of pocket with your co pay if your DME would supply the new machine?
Would ordering what you want online be possible?

Grandpap has a nice little machine for sale.
viewtopic.php?f=1&t=81313&p=739614&hili ... le#p739614

[chunkyfrog]

I bought mine online--the S9 Elite from the DME is resting in the closet--(my unknown backup).

[brucifer]

I think you need to give BCBS a call and explain your situation to them. I bet they grant you a new machine.

By all means, DO NOT break your existing machine. Go about things the right way. If you have to, get your doctor to write a letter in your behalf. Besides, you can always use your old machine as a back up once you get your new machine.

Keep us posted. Good luck!

[Xney]

If the insurance says you can get a new one at 5 years, there's no reason for the DME to balk at it. In fact, they'll make money replacing it.

Upgrade fee or whatever is nutty. Can you use a different DME?

[Tino2You]

I agree with mayondair. Ask you doc to write the script for an s9 Autoset with 12-15 pressure (or something like that). Humidifier,Climate line hose, new mask and most important, DO NOT SUBSTITUTE. (You can substitute your PR machine of your choice in place of the S9)

-tino

[robysue]

I'd start by contacting the insurance company to clarify your benefits.

If the insurance company will pay for a new machine based on the age of your current one and your doc's script, let them know the DME is being difficult. Be sure to provide as much specific info as you can: The DME's name, the person you spoke with, and exactly what they said. And start shopping around for a new DME. And let the current DME know that you're planning on taking your business elsewhere and why.

If the insurance company says they won't cover a new machine, find out about the appeals process AND have the doc write a letter of medical necessity and send it to the insurance company along with giving you a copy of your letter. A letter of medical necessity is different from the prescription.

[brucifer]

I agree with mayondair. Ask you doc to write the script for an s9 Autoset with 12-15 pressure (or something like that). Humidifier,Climate line hose, new mask and most important, DO NOT SUBSTITUTE. (You can substitute your PR machine of your choice in place of the S9)

-tino

tino, the doctor can write the Rx, but if BCBS is not going to cover paying for the new machine, then the OP will have to pay out of pocket. It's better to go straight to the insurance company to get answers or to make an appeal.

[schnertling]

*** UPDATE ***

I spoke with BCBS today & explained my situation. They said I am absolutely entitled to a new machine....no argument, no fuss. Funny how the DME claimed that they "spoke to my insurance company" and they didn't approve a new machine. Really?!?!?

BCBS also said that all machines and supplies are directly billed to BCBS if the provider is in network so I should NOT pay for anything out of pocket.

It's amazing how someone can be a healthcare provider (ie DME), lie and / or take advantage of patients and still sleep at night.

Thank you everyone for all the great advice.....I was getting close to throwing in the towel.

[archangle]

Sounds like an excellent time to find a new DME (CPAP salesman). Then tell the old DME why they've lost your business.

[Tino2You]

*** UPDATE ***

I spoke with BCBS today & explained my situation. They said I am absolutely entitled to a new machine....no argument, no fuss. Funny how the DME claimed that they "spoke to my insurance company" and they didn't approve a new machine. Really?!?!?

BCBS also said that all machines and supplies are directly billed to BCBS if the provider is in network so I should NOT pay for anything out of pocket.

It's amazing how someone can be a healthcare provider (ie DME), lie and / or take advantage of patients and still sleep at night.

Thank you everyone for all the great advice.....I was getting close to throwing in the towel.

First rule of DMEs...they lie.
Second rule of DMEs...even when they are not lying, they are clueless/ruthless/money grubbers....

To paraphrase "THE MOST INTERESTING MAN OF THE WORLD" ... no not gonna say "stay thirsty my friends" ... STAY VIGILANT MY FRIENDS!
-tino