Insurance changed my CPAP equipment (presumably without notifying my doctor)

Hi there. I’ve been diagnosed with mild sleep apnea for a few months now and it’s been taking a bit long to get the machine. That’s understandable given the shortage and all. But now I’m running into a problem with insurance.

When I went to the doctor, I specifically asked for a ResMed Airsense 10 because I got the impression the 11 wasn’t that big of an upgrade, and also I wanted the swivel on the back of the machine to make sleeping a bit more flexible. He said okay and prescribed the Airsense 10 Auto without a modem (although the modem part seemed to be optional for the provider).

Today, I asked the DME to confirm the equipment I’ll be picking up this Friday. They told me it’d be a ResMed Airsense 11 with a modem. The modem is whatever, but the DME said that my insurance demanded live information updates, so they changed it to the 11 (it seems like they could’ve just done that with the 10). I’ve already messaged my doctor so I’m waiting for him to respond. But I was searching for the equipment list and I guess he didn’t make it accessible to me, or perhaps I misplaced it.

Either way, is insurance allowed to just change my prescription like that? Also, should I just accept the 11? The lack of sleep is killing me and I just want to try the CPAP ASAP so see if it works or not, especially with school starting again. I believe my doctor said I’ll need to try the CPAP before he starts treating me for narcolepsy which is why I don’t want to delay any further if I can.

ResMed APAPs, both 10 and 11, are excellent machines.

Balancing (1) the preferences of the patient, (2) the requirements of the patient's insurance, (3) the intent of the doctor, and (4) the machinations and pure laziness of some durable medical equipment companies can be a delicate dance.

But the bottom line, I would think, is that either machine should do well at meeting your needs, as long as it is an APAP.

Insist on an AUTOSET.
Airsense 10 or Airsense 11, but only the Autoset.
Anything but an Autoset--and you are screwed!

It's highly unlikely that your "insurance changed the order" except, perhaps, to require the modem for compliance documentation, but even that's dubious. Most insurers pay by HPCP codes, it's the same code (and same reimbursement) for either machine, and they don't care which you get as long as you meet their compliance requirements.

However, there's nothing wrong with the ResMed 11 AUTOSET, so if that's really what you are getting, that's perfectly OK.

More than likely, the 11 is what the DME had in stock, and AS LONG AS IT IS THE AUTOSET it's still a fine machine. Make sure the DME didn't play bait and switch and give you a fixed CPAP or Elite to increase their profit margin. The Elite and CPAP are fixed pressure models, CPAP doesn't even have efficacy data--they cost less than the Autoset, but the DME gets paid the same regardless of which model you get, so there's an incentive to give you a cheaper machine to increase the profit margin. Hopefully someone here will come along to tell you how to check which model it is before you accept it, once it's in your possession you're going to find it impossible to exchange.

I have a saying: Never, never, never, ever, ever, ever trust what a DME says without confirming. You can call your insurance company and ask if they pay by HPCP codes or they require you to get a specific model of ResMed machine. Prepare for a "huh?" from the company.

Janknitz wrote: ↑

Mon Jan 16, 2023 6:18 pm

However, there's nothing wrong with the ResMed 11 AUTOSET, so if that's really what you are getting, that's perfectly OK.

…

More than likely, the 11 is what the DME had in stock, and AS LONG AS IT IS THE AUTOSET it's still a fine machine. Make sure the DME didn't play bait and switch and give you a fixed CPAP or Elite to increase their profit margin.

chunkyfrog wrote: ↑

Mon Jan 16, 2023 6:07 pm

Insist on an AUTOSET.
Airsense 10 or Airsense 11, but only the Autoset.
Anything but an Autoset--and you are screwed!

lazarus wrote: ↑

Mon Jan 16, 2023 6:00 pm

ResMed APAPs, both 10 and 11, are excellent machines.

…

But the bottom line, I would think, is that either machine should do well at meeting your needs, as long as it is an APAP.

I’m getting the Autoset, but I keep forgetting to specifically mention the “autoset” when asking them about it. Thanks for the reminder.

Janknitz wrote: ↑

Mon Jan 16, 2023 6:18 pm

I have a saying: Never, never, never, ever, ever, ever trust what a DME says without confirming. You can call your insurance company and ask if they pay by HPCP codes or they require you to get a specific model of ResMed machine. Prepare for a "huh?" from the company.

I’ve been researching CPAP for a while now, so I was fully prepare to be disappointed by DMEs before going in, so no surprises there. I’ll be making a detailed list of things I’m expecting and calling in tomorrow to see what they have to say. I’m waiting for my doc to reply with the actual list he wrote as well, hopefully it’s sent before Friday.

Thanks everyone for the advice.

Be sure to get a copy of the doctor’s prescription for the machine (and mask and whatever). It could be useful for you to have down the road. Also get a copy of your sleep report, for the same reason.

I understand your disappointment in not getting the machine you wanted. But the AirSense 11 isn't exactly a downgrade. I think you'll grow to like it. I do understand wanting the swivel instead of the connector that comes on the AirSense 11, but I'd be willing to bet that you won't notice after a short while.

When I was clicking on the link to this thread I anticipated reading how you wanted a ResMed and were instead being given a Luna II or a DreamStation. As DME battles go, yours is a lot better than it could be.

the part number you can purchase from Resmed is 37394 and that will allow you to have a swivel on the hose.

mets123 wrote: ↑

Tue Jan 17, 2023 3:26 pm

the part number you can purchase from Resmed is 37394 and that will allow you to have a swivel on the hose.

Not if he uses a heated hose.

And I wouldn't consider a 90-degree elbow a swivel. While it can help a lot orienting the direction of the hose, they are too tight to swivel.

LizardBBQ wrote: ↑

Mon Jan 16, 2023 5:34 pm

I got the impression the 11 wasn’t that big of an upgrade

Your impressions really don't amount to anything much interms of sucessful therapy outcomes.

The modem is whatever, but the DME said that my insurance demanded live information updates, so they changed it to the 11 (it seems like they could’ve just done that with the 10).

The WAN cards for the A10 are in very short supply due to COVIID-10 related supply chain issues.

Either way, is insurance allowed to just change my prescription like that?

Since it's absolutely a like-for-like change, yes they are.

LizardBBQ wrote: ↑

Mon Jan 16, 2023 5:34 pm

They told me it’d be a ResMed Airsense 11 with a modem. The modem is whatever, but the DME said that my insurance demanded live information updates, so they changed it to the 11 (it seems like they could’ve just done that with the 10).

As already mentioned either Autoset will do but I'm not aware that any insurance (nor the DME) can change what any Dr orders. You can call your insurance if you want to be sure but this smells fishy and will likely lead to more misinformation later.

Always speak directly with your insurance when any DME makes those kind of statements.

Do remember that should you want the AS10 Auto ask your Dr. to write that make & model along with "No Substitutes" on the equipment request then they will have no choice but to fill it as ordered.

HTH

I agree that the "swivel" on the Airsense 10 models is not freely rotating,
which would make it, IMO, a true swivel.
The connection has a range of positions, but once one is chosen-
-it stays until you push it into another direction--NOT a swivel.
And the positions are limited.
Not really a big deal . . .

chunkyfrog wrote: ↑

Tue Jan 17, 2023 7:53 pm

I agree that the "swivel" on the Airsense 10 models is not freely rotating,
which would make it, IMO, a true swivel.
The connection has a range of positions, but once one is chosen-
-it stays until you push it into another direction--NOT a swivel.
And the positions are limited.
Not really a big deal . . .

Did not know this. Thanks for the clarification

SleepGeek wrote: ↑

Tue Jan 17, 2023 7:34 pm

Do remember that should you want the AS10 Auto ask your Dr. to write that make & model along with "No Substitutes" on the equipment request then they will have no choice but to fill it as ordered.

HTH

I’ll keep this in mind, but it seems like the 11 is a good choice so I rather not go through the hassle. I want to sleep as soon as possible rather than wait another 3+ months.

I do have another question now. I don’t remember where I saw this, but someone advised that a certain number of hours logged into a brand new machine is acceptable because it could be the provider turning it on and testing its functionality. But I don’t remember the specifics.

So my question is, what are the “acceptable” number of hours in usage for a brand new machine from a DME?

Janknitz wrote: ↑

Mon Jan 16, 2023 6:18 pm

It's highly unlikely that your "insurance changed the order" except, perhaps, to require the modem for compliance documentation, but even that's dubious. Most insurers pay by HPCP codes, it's the same code (and same reimbursement) for either machine, and they don't care which you get as long as you meet their compliance requirements.

However, there's nothing wrong with the ResMed 11 AUTOSET, so if that's really what you are getting, that's perfectly OK.

More than likely, the 11 is what the DME had in stock, and AS LONG AS IT IS THE AUTOSET it's still a fine machine. Make sure the DME didn't play bait and switch and give you a fixed CPAP or Elite to increase their profit margin. The Elite and CPAP are fixed pressure models, CPAP doesn't even have efficacy data--they cost less than the Autoset, but the DME gets paid the same regardless of which model you get, so there's an incentive to give you a cheaper machine to increase the profit margin. Hopefully someone here will come along to tell you how to check which model it is before you accept it, once it's in your possession you're going to find it impossible to exchange.

I have a saying: Never, never, never, ever, ever, ever trust what a DME says without confirming. You can call your insurance company and ask if they pay by HPCP codes or they require you to get a specific model of ResMed machine. Prepare for a "huh?" from the company.

I don’t trust the DME companies either. Sometimes when I find myself in the situation where the DME and insurance company tell me different stories (blame game), I say, well, let’s do a 3-way call to come to a correct understanding of the facts.