No Medical Necessity to replace a Brick

Thatgirl · Post by **Thatgirl** » Thu Dec 17, 2015 6:49 pm

Threads like this make me realize just how lucky I was when I got my CPAP. I was not interested it getting one AT ALL and had no idea about anything new about them. It was my doctor that insisted on me getting an auto titrating machine, and the DME that told me if I could wait a week they could get me the Airsense 10 model that they had on order instead of the Icon they had in stock. I had no idea how lucky I was.

WindCpap · Post by **WindCpap** » Thu Dec 17, 2015 7:13 pm

I agree with the DME. There is no absolute medical necessity to have a full data machine.... Of course, there is a 6 month followup sleep study as well as a new sleep study every couple of years required to ensure that treatment is still effective.

I am glad I live in Ontario were, although the requirements for getting an APAP are quite strict, the minimum machine is data capable. Under the assistive devices program, the government pays for 75% of the cost, and regulates the prices on the machines. I think somebody did the math and figured out that the extra cost for the better machine is substantially less the the cost of the follow-up sleep studies.

ChicagoGranny · Post by **ChicagoGranny** » Thu Dec 17, 2015 7:24 pm

davep700 wrote:She says that there is no medical necessity for a data capable machine

Why do you think you need a data capable machine?

davep700 · Post by **davep700** » Fri Dec 18, 2015 9:17 am

chicagograny I'm satisfied with the explanation above: There is no medical necessity for CPAP machine statistics if you do the (expensive) follow up sleep studies as needed.

It's not my realm, but perhaps Insurance companies can consider the cost of follow up sleep studies and mandate data-capable machines for apnea patients. Then the patients and doctors will slowly make use of the stats and begin to trust and integrate them into treatment.

That said, I think I will buy my machine rather than trying to make the "snowball's chance in hell" for a free exchange . If I get a machine from another DME without the compliance monitoring modem, do insurance companies generally continue paying for cpap supplies , etc? Will I be able to print a proper usage report for the doctor? Probably I should give the insurance company a call...

ChicagoGranny · Post by **ChicagoGranny** » Fri Dec 18, 2015 9:37 am

davep700 wrote:If I get a machine from another DME without the compliance monitoring modem, do insurance companies generally continue paying for cpap supplies , etc?

It seems they generally do. Most insurance companies follow Medicare guidelines for all their customers. This requires an annual statement from the doctor that you still have sleep apnea, you are compliant with usage of CPAP, and your symptoms are treated with CPAP. Some will also require a new CPAP prescription before they pay for supplies.

davep700 wrote:Will I be able to print a proper usage report for the doctor?

I take the machine SD card to the sleep doctor on my annual visit, and they prepare the report. You might want to check with your doctor's office.

davep700 wrote: If I get a machine from another DME

Which machine are you planning to purchase? You may know that it is often the case that internet suppliers are cheaper than brick-and-mortar DMEs. Our forum host, cpap.com, is one internet supplier, and they do match prices.

WindCpap · Post by **WindCpap** » Fri Dec 18, 2015 10:51 am

I'm a bit confused. The machine in your profile is a data capable machine. The only machine that comes with a modem out of the box as far as I know is the Resmed Airsense 10, and the over-air data is fairly minimal.

Also, nobody has every lost weight simply because they started CPAP. Your weight loss efforts may be easier withCPAP than without.

OkyDoky · Post by **OkyDoky** » Fri Dec 18, 2015 11:18 am

WindCpap wrote:I'm a bit confused. The machine in your profile is a data capable machine. The only machine that comes with a modem out of the box as far as I know is the Resmed Airsense 10, and the over-air data is fairly minimal.

Also, nobody has every lost weight simply because they started CPAP. Your weight loss efforts may be easier withCPAP than without.

He has reported to have a Brick. REMStar Plus, DOM REF 260P. REV 01 3.XX

grayghost4 · Post by **grayghost4** » Fri Dec 18, 2015 11:24 am

Quote: Fortunately, I am going to my visit my PCP tomorrow. I assume I need to inqurie about a prescription worded as, "data capable CPAP machine @ pressure 12cmh2o".

I would suggest :: data capable CPAP machine @ pressure 10-14 ..... that will force an auto, which are data capable .

chunkyfrog · Post by **chunkyfrog** » Fri Dec 18, 2015 3:21 pm

If the brick is a RENTAL, it does not seem unreasonable to cancel the rental and return the machine.
{{check with your insurance}}
You could then purchase a full data blower online for far less than the "thousands" that the piggy DME told you!

flightco · Post by **flightco** » Fri Dec 18, 2015 9:02 pm

davep700 wrote:
Janknitz wrote: Anyway, you're going to have to grow a pair and get fully educated to have a snowball's chance of getting your DME to replace the brick, RX or not. So if you're not the assertive type, ....
That's what I wanted to do first - get fully educated ... Thanks for assuming that I'm balless and unassertive..

Why, oh why do people come here, ask for advice, get advice from people who give of their time and experience to newbies over and over, year after year and then the newbie does not like a comment and gets pissed off and snarky. Don't take things so seriously, they are trying to help you. It was advice, you asked for advice...

flightco · Post by **flightco** » Fri Dec 18, 2015 9:03 pm

grayghost4 wrote:Quote: Fortunately, I am going to my visit my PCP tomorrow. I assume I need to inqurie about a prescription worded as, "data capable CPAP machine @ pressure 12cmh2o".

I would suggest :: data capable CPAP machine @ pressure 10-14 ..... that will force an auto, which are data capable .

Great advice Grayghost

flightco · Post by **flightco** » Fri Dec 18, 2015 9:08 pm

Michelle-OH wrote:Yes, that's my machine and I haven't even figured out how to access the data because it seems so difficult( so not good with tech stuff)
I called my DME provider to see if I could just bring back the Luna, which I got on 12/01/15, she said she wasn't sure and would get back with me. I can't imagine no one has tried to return one in the past?? I have to pay the $45 for 9 mos. So, buying the $200 would be a great savings, although I have some concern about giving someone $200 before I know the machine is in top condition, etc.
Pugsy wrote:
Michelle-OH wrote: I wonder if this machine would be better than my Luna? It would certainly be much cheaper than the $45 I am going to have to pay monthly, for 9 months to my DME provider under my insurance?
Is this your machine?
https://www.cpap.com/productpage/3b-lun ... ifier.html

If it is I would take the PR S1 Pro CPAP model 460, which is what is offered for $200 in the thread I mentioned,
hands down over the Luna even if it didn't save me money on total out of pocket costs.
The Luna doesn't offer the depth of data detailed offered on the 460. It does offer some data so it isn't a "brick" but it offers numerical data only and no graphs to show exactly when and what happened.
Numbers don't always tell us the whole truth and sometimes leave a lot of unanswered questions.

Not to mention the fact that Respironics and ResMed have a long history of providing quality cpap products.
The Luna is marketed as a "budget" product to suppliers so that they can optimize profit.
In simple terms...it's cheaper and since insurance typically pays the same no matter what brand is used then the DME makes more money.
When it comes to my health I don't know that "cheaper" is where I want to go just so some DME can make more money....not when a viable other alternative that is tried and proven is available.

So I would definitely go with the 460 before I would go with the Luna for a bunch of reasons.

How long are you supposed to be paying that $45 a month before you don't have to pay it anymore?

What would happen if you told them you are no longer going to pay the 45 dollars and you want to return it? Do you have a binding contract? If you do, you might be stuck with it but rental is usually so if you are not compliant the insurance company can have it returned to the DME

davep700 · Post by **davep700** » Fri Dec 18, 2015 10:41 pm

Strange thing, my PCP did not want to write an Rx for a machine. He said that it could come back to haunt him, because my insurance company could inquire of him what made the new more expensive device suddenly necessary and he wouldn't have a suitable answer.

flightco · Post by **flightco** » Fri Dec 18, 2015 11:32 pm

davep700 wrote:Strange thing, my PCP did not want to write an Rx for a machine. He said that it could come back to haunt him, because my insurance company could inquire of him what made the new more expensive device suddenly necessary and he wouldn't have a suitable answer.

I feel for you, you are stuck with PCP and PA who understand very little about the illness they are trying to treat and have made the decision to go along to get along.

Thatgirl · Post by **Thatgirl** » Sat Dec 19, 2015 12:51 am

davep700 wrote:Strange thing, my PCP did not want to write an Rx for a machine. He said that it could come back to haunt him, because my insurance company could inquire of him what made the new more expensive device suddenly necessary and he wouldn't have a suitable answer.

I really hope your insurance company has better things to do than audit physicians for writing OSA patients CPAP scripts It would be extremely easy to document need for an APAP. "Patient continues reporting daytime fatigue/headaches/depression/whatever. Will try auto titrating machine to maximize therapy, and audit machine data to determine AHI is consistently being kept below 5." Done. Need for APAP documented.

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Additional Comments: Vauto EPAP min 5, IPAP max 25, PS 6