Another Evil DME......Cflex vs. no Cflex

Sleepy Dog Lover · Post by **Sleepy Dog Lover** » Tue May 02, 2006 3:35 pm

Hi all, I've been lurking for a few weeks since I found out that I have OSA. The posts have been most helpful, thanks much. I finally have my pressure and an appointment with the DME on Thursday. I called the DME to find out what my machine options are. They will not give me a machine with Cflex or EPR unless the Dr. puts it on the prescription. I feel like this is Deja Vu all over again, I think I read this somewhere on this forum.

I already pushed with my Dr (primary care) to get the heated humidifier (the sleep doc recommended a baffle or passover humidifier) and that was successful. The pressure recommendation from the titration study was 11cm. I know that everybody is different, and what works for one might not work for another. With that said, does anybody have any opinions on how I might tolerate an initial pressure of 10 without cflex or epr, keeping in mind that this is all new to me.

They are also trying to push me towards a Fisher & Paykel HC231 which is not a machine I have heard mentioned much on this board. If I go through the DME, everything is 100 covered by insurance. If I buy one myself from the internet, I have a $300 deductable and a 20% copay. Of course, the DME says that I can pay the $400 difference between cflex and non cflex.

All comments are welcome.

3isles · Post by **3isles** » Tue May 02, 2006 4:09 pm

If you have the prescription in your hot little hands, why don't you check out the online prices. See what you can get for the $700.00+ they're telling you you will have to pay yourself. My DME charged insurance (on paper anyway) nearly a grand for something I could buy online today for less than $400.00. If you know you will have to pay cash anyway, get the best for your $$.

Wulfman · Post by **Wulfman** » Tue May 02, 2006 4:17 pm

SDL,

So many of these insurance situations are different.
Will your insurance provider reimburse YOU 100%?
Have your deductibles been met by the sleep study and doctors visits, etc.?

What I advocate is for people to buy the equipment they really want from CPAP.COM and then bill their insurance provider (the invoice would be from you and not CPAP.COM). In most cases, the insurance provider will reimburse the plan member at "in-network" rates. If your DME is considered "in-network", then YOU should be considered "in-network". Virtually all insurance providers will reimburse their members for out-of-pocket (approved) medical necessities that are covered by the plan.
Make sure that you get the (original) prescription from your doctor....preferrably the way YOU want it to read. On the other hand, I don't believe that your prescription HAS to say C-Flex if you purchase the (Respironics) machine from CPAP.COM although it might be easier to get it reimbursed through your insurance if it has C-Flex and heated humidifier on it. Remember, your doctor is working for YOU. It's going to be YOUR therapy and you need the optimum equipment to make it successful. You're going to be the one to have to sleep with this stuff every night....not them.
Do NOT settle for stuff you don't want.

Best wishes,

Den

txtornado · Post by **txtornado** » Tue May 02, 2006 5:19 pm

With that said, does anybody have any opinions on how I might tolerate an initial pressure of 10 without cflex or epr, keeping in mind that this is all new to me.

Hi there. I have only been on xPAP for one month and was also prescribed a pressure of 11cm. I decided to buy an Auto PAP instead of a straight CPAP, and I also decided that I could live without C-Flex or EPR. I had 2 reasons for not buying a machine with C-Flex or EPR. 1 - I had read several posts here that people using C-Flex/EPR had problems with aerophagea. I already have enough digestive problems that the idea of waking up with a belly full of air was very unappealing. 2 - They were $150-$200 more expensive and I had to pay for everything out of pocket and on a limited budget.

I decided on an APAP because the machine adjusts the pressure throughout the night instead of just running at one set pressure, so I wouldn't always be exhaling against 11cm. I hoped that when the machine did kick up to higher pressures I'd be asleep and wouldn't notice the difference anyway.

After one month using my APAP and monitoring the data I have found that is exactly what's happening. I set my pressure range from 7cm to 14cm. I also set my machine with a 30-minute ramp time so that even building up to the low end of 7cm was gradual. Most nights I spend a lot of time at 8 or 9. The higher pressures almost always kick in very late at night when I'm sound asleep (and how wonderful it is to be able to say "sound asleep" again!). So if it's harder to exhale at the higher pressure, I'm blissfully unaware of it.

Granted, even with the Auto and ramp time, the first 2-3 weeks were not fun. It felt really weird, and sometimes pretty uncomfortable, to have that air blowing into my nose. There was definitely an adjustment period, no matter how low or high the pressure. But now that I'm in my fifth week, I find that the pressure is really easy to take. Just last night I kept putting my hand up by the air ports to make sure the thing was really on.

I know that there are people who think C-Flex/EPR is a necessity. But I was really concerned about aerophagea and the extra cost. Doing APAP without C-Flex/EPR is working well for me. If I had been prescribed a pressure of 15 or above, I might have looked at C-Flex/EPR differently. But I really think that a pressure of 11cm is tolerable without it.

Good luck working through everything with your insurance company. And keep coming here for advice - this board has been invaluable to me and many others trying to get through xPAP therapy.

Wulfman · Post by **Wulfman** » Tue May 02, 2006 5:53 pm

You can turn C-Flex off on the Respironics machines.
You can turn EPR off on the ResMed machines. In fact, the EPR doesn't function in "auto" mode.

Den

Sleepy Dog Lover · Post by **Sleepy Dog Lover** » Tue May 02, 2006 6:04 pm

Wulfman, my insurance is a PPO. If I stay with an in network DME (one of which is Apria) they pay 100% for the cpap etc. If I go out of network, I have to pay a $300 deductable plus 20%. So it is definitely a big difference in my out-of-pocket. The DME (I chose the one OTHER than Apria, but Apria said the same thing) said that they would not give me a cflex unless it was on the prescription, under the insurance plan. The provider that I am going with said that they could as long as I paid the difference which they told me was about $400. Ridiculous, especially looking at the prices at cpap.com. The DME is entitled to a profit, I have no problem with that, but the addition of cflex does not add $400.

I am going to the appointment on Thursday, and I will be taking a copy of the online prices with me. I thought about taking the machine and then complaining loudly that I can't exhale, if I can't, I just don't see why I should have to go through that. What I may do is get the machine that they give me, and order a backup from cpap.com. I would be out the entire amount of money, but the difference would be less than $150.

I guess they have to keep those profit margins up.

th · Post by th » Tue May 02, 2006 6:05 pm

My 2 cents is ....buy here (cpap.com) and use your insurance and get the RemStar auto with C Flex and Heated humidifier. You sleep 1/3 of your life why not pick out what you want.

Sleepy Dog Lover · Post by **Sleepy Dog Lover** » Tue May 02, 2006 6:07 pm

I was actually thinking about getting the Respironics M series with cflex and heated humidifier. God I hate insurance companies!

Wulfman · Post by **Wulfman** » Tue May 02, 2006 6:43 pm

Sleepy Dog Lover wrote:Wulfman, my insurance is a PPO. If I stay with an in network DME (one of which is Apria) they pay 100% for the cpap etc. If I go out of network, I have to pay a $300 deductable plus 20%. So it is definitely a big difference in my out-of-pocket. The DME (I chose the one OTHER than Apria, but Apria said the same thing) said that they would not give me a cflex unless it was on the prescription, under the insurance plan. The provider that I am going with said that they could as long as I paid the difference which they told me was about $400. Ridiculous, especially looking at the prices at cpap.com. The DME is entitled to a profit, I have no problem with that, but the addition of cflex does not add $400.

I am going to the appointment on Thursday, and I will be taking a copy of the online prices with me. I thought about taking the machine and then complaining loudly that I can't exhale, if I can't, I just don't see why I should have to go through that. What I may do is get the machine that they give me, and order a backup from cpap.com. I would be out the entire amount of money, but the difference would be less than $150.

I guess they have to keep those profit margins up.

SDL,

I'm not sure what "PPO" means.....
However.....your insurance provider SHOULD CONSIDER YOU as being "in-network" when they (presumably) reimburse you for an out-of-pocket purchase. YOU would not be considered "out-of-network"!
If you were visiting in another state and you needed to purchase some medication (out-of-pocket).......would your insurance provider reimburse you for those medications?

Ask your "PPO" if they are even remotely interested in saving any money?

Den

Guest · Post by **Guest** » Tue May 02, 2006 7:23 pm

Sorry Den, a PPO is a Preferred Provider network. It is one step above an HMO, you can go out of network and use it as regular insurance, with a deductable and 20% copay after the deductable is met. Everything I have done this year, including the sleep study have been in-network, and haven't cost me a penny. I do realize that I am lucky in that part of it. It doesn't matter to the insurance company if you can save them money, they have contracts with the providers and if you go out of network, you go out of network.

I hate insurance companies, I hate insurance companies, I hate insurance companies.

I'm working on getting a prescription from my Dr that includes cflex. Thanks for your comments.

DME_Guy · Post by **DME_Guy** » Tue May 02, 2006 10:52 pm

The difference in cost to the DME between a Remstar Plus and a Remstar Plus with C-flex is about a $100.

Sleepy Dog Lover · Post by **Sleepy Dog Lover** » Tue May 02, 2006 11:13 pm

Thanks much DME_Guy, thats about what I figured. Well, I figured it was $150 or less, so I was close. I hope I can just get the scrip from my doc and not have to deal with all this.

octaldave · Post by **octaldave** » Wed May 03, 2006 12:22 am

I just started my therapy in the middle of February, and with a 12cm pressure. I was very concerned about being able to breathe out, especially after the first night!

I fiddled with my auto and c-flex levels constantly during my first two weeks, trying to get more comfortable with the pressure, and correlating how I felt with the EncorePro data.

For me, c-flex was a waste of time. It would allow you to breathe out with less effort, but only after you applied a certain amount of force yourself in order to get the machine to "release" pressure. It was not very natural, and somewhat distracting to fall asleep this way. Additionally, I would notice my apneas increase dramatically the higher the c-flex setting. Of course not everyone feels the same way, and perhaps I'm in the minority, but ca-flex merely got me through the first week of getting accommodated to the pressure. I'm sure that most do feel, however, that it only takes a few weeks of this exercise against the machine before even large pressures become unnoticeable.

Use a long ramp time if you need to, but stick with it and enjoy the benefits! I believe that by the time it is all said and done, this therapy will have added 40 years to my life. Just don't let the first few weeks throw you off, c-flex or no c-flex.

LDuyer · Post by **LDuyer** » Wed May 03, 2006 7:07 am

Sleepy Dog Lover,

It sounds like you're not sure yet if you will use a local DME or an online one.

But if you go with Apria and you haven't decided on a mask, be sure to convince them to show you several kinds.

I actually showed up at a large local Apria dealer, just when they were about to have a meeting with about six of their new clients who were picking up their cpap machines and masks. I asked to sit in and listen, I wasn't purchasing at the time. Nearly all of them had already had their machines arranged and this was just to give them their machines and show them how to use it, with a few respiratory lessons thrown in for good measure.

But I noticed that they were all given the same mask brand. They did not question the masks nor were they told there were other kinds. One man seated next to me was not there to pick up a machine, just to ask questions. It was clear he didnt know much either. So, being the devilish person I am, I passed a quick note to the guy saying, "Ask about the different types and brands of masks." Haha! Well, he did. This prompted the Apria guy to bring in a couple of other brands, but only because the guy asked.

Every DME seems to be a little different in their customer service. My point is, ask questions. And if you go to a local one, ask about the different masks if you need to know. They may or may not volunteer that kind of information. You may have to ask.

Linda

CrystalP · Post by **CrystalP** » Wed May 03, 2006 8:15 am

How do you guys know all this stuff? Granted, I am totally new to this but I really feel like a complete idiot! What is a DME anyway?

Another Evil DME......Cflex vs. no Cflex

Another Evil DME......Cflex vs. no Cflex

Thanks so much for your replies

Re: Thanks so much for your replies