Replacement Schedules?

Babette · Post by **Babette** » Fri Apr 10, 2009 9:11 am

I feel for you. {{{{{{Kiralynx}}}}}}}

It's bad enough to go through this when you're getting therapy. Having a wicked head cold, and off the hose, it's MURDER!!!!!!

Sorry, buddy.
B.

Kiralynx · Post by **Kiralynx** » Fri Apr 10, 2009 9:38 am

Well, as I've reported in the Probasics Zzz-mask thread,

viewtopic/t40716/New-Probasics-Zzz-Mask-Thread.html

I was able to get a mask by overnight delivery from CPAP.COM, and have now adapted it to work tolerably well for me in the trying circumstances.

But I was apparently so tired last night that when my two fixes made the mask comfortable, I conked fairly completely. Had a higher leak rate last night from two large leaks that I apparently slept through! (Rest of the night was a rate within normal parameters for either of my nasal pillows mask, but have not yet found a leak rate chart for the Zzz-mask.)

Like I said, lots of feel-good, and "I'll get back to you on Wednesday."

The Texan · Post by **The Texan** » Fri Apr 10, 2009 7:03 pm

6PtStar wrote:
JoyD. wrote:Kiralynx,

States differ for Medicare replacement schedules. For example, here in Kentucky Medicare will only replace a mask every 6 months, not 3 months.

Better check your own state Medicare schedule. A good DME SHOULD know it, mine gave me a printout.

Joy
Joy, I got caught in that 3 month thing. They told me that yes I could replace the mask every 3 months but the headgear is replaceable only every 6 months. The kicker was that they won't sell the mask without the headgear so that puts you in the 1 every 6 months category. If they sold the mask without the headgear you could actually get 1 every 3 months.

Jerry

something is very fishy here. My DME told me that Medicare will pay for a new mask every 3 months and if the mask comes from the manufacture with headgear attached, then I will also get it at 3 months. I am having trouble finding any information that says Medicare is different in every state, only thing I can find says national or all 50 states are the same. Now Medicaid is different in every state. If someone has a valid reference that Medicare differs by state, other than the word of a DME, please post it.

6PtStar · Post by **6PtStar** » Fri Apr 10, 2009 8:40 pm

OutaSync wrote:Is this what you are looking for?

ACCESSORIES:
Accessories used with an E0601 device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not medically necessary.

The following table represents the usual maximum amount of accessories expected to be medically necessary:

A4604 - 1 per 3 months: tubing used with a heated humidifier and has a heated wire running the length of the tubing.

A7027 - 1 per 3 months:(Combination oral/nasal mask, used with continuous positive airway pressure device, each)is a two
piece system with separate elements for oral and nasal use.

A7028 - 2 per 1 month: Replacement cushion combination oral/nasal mask.

A7029 - 2 per 1 month: Replacement nasal pillows for combination oral/nasal mask

A7030 - 1 per 3 months: Full Face Mask

A7031 - 1 per 1 month: Replacement cushion for full face mask.

A7032 - 2 per 1 month: Replacement cushion for nasal mask

A7033 - 2 per 1 month: Replacement pillows for nasal mask.

A7034 - 1 per 3 months: Nasal Mask

A7035 - 1 per 6 months: Headgear

A7036 - 1 per 6 months: Chinstrap

A7037 - 1 per 3 months: Tubing

A7038 - 2 per 1 month: Disposable filter

A7039 - 1 per 6 months: Non-Disposable filter

A7046 - 1 per 6 months: Replacement water chamber for humidifier

Revision Effective Date: 01/01/2008
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Usual maximum quantity parameters for new HCPCS codes - A7027, A7028, A7029
HCPCS CODES:
Added: A7027, A7028, A7029

ACCESSORIES
A4604 - Tubing with integrated heating element for use with positive airway pressure device
A7027 - Combination oral/nasal mask, used with continuous positive airway pressure device, each
A7028 - Oral cushion for combination oral/nasal mask, replacement only, each
A7029 - Nasal pillows for combination oral/nasal mask, replacement only, pair
A7030 - Full face mask used with positive airway pressure device, each
A7031 - Face mask interface, replacement for full face mask, each
A7032 - Cushion for use on nasal mask interface, replacement only, each
A7033 - Pillow for use on nasal cannula type interface, replacement only, pair
A7034 - Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 - Headgear used with positive airway pressure device
A7036 - Chinstrap used with positive airway pressure device
A7037 - Tubing used with positive airway pressure device
A7038 - Filter, disposable, used with positive airway pressure device
A7039 - Filter, non disposable, used with positive airway pressure device
A7044 - Oral interface used with positive airway pressure device, each
A7045 - Exhalation port with or without swivel used with accessories for positive airway devices, replacement only
A7046 - Water chamber for humidifier, used with positive airway pressure device, replacement, each
E0561 - Humidifier, non-heated, used with positive airway pressure device
E0562 - Humidifier, heated, used with positive airway pressure device

ALSO:
A continuous positive airway pressure (CPAP) device (E0601) delivers a constant level of positive air pressure (within a single respiratory cycle) by way of tubing and a noninvasive interface (such as a nasal, oral, or facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs.

For auto-titrating CPAP devices use HCPCS code E0601.
NOTE - CPAP and APAP covered on E0601.

Accessories are separately reimbursable at the time of initial issue and when replaced.
NOTE - This last sentence is why DME's charge kit items separately when new. It's cheaper for them to get the kit and they get the same payment as if they provided the separate parts. But WE get the bag, etc that Medicare and other insurances wouldn't necessarily cover.

If you look at OutaSync's list and if you have ever looked at your bill from your DME the mask and headgear are always billed as seperate items. I was given the exact list that OutaSync posted by a lady at Medicare. I have not been able to find anything that says that it can be different in every but I would not bet on that being correct. I talked to a couple of mask manufacturers and they told me that they would sell the mask without the headgear (even gave me the separate part numbers for each)but that the DME's did not like to buy the mask and headgear seperately because it was more expensive buying them seperate and if they buy them together and they sell you just the mask chances are that they are going to keep the headgear. More of an inventory problem for them.

Jerry

Kiralynx · Post by **Kiralynx** » Wed Apr 15, 2009 4:39 pm

Updating on the Replacement Schedule Business.

I heard back from the woman with HR today... she had my answer! She reached out to Aetna... and I can have two masks a year!

Which was not what I asked. I asked about getting masks under an emergency situation. The answer: if I want the insurance to pay for it, I have to give Apria 5-7 days to order something.

OK, fine, let's discuss replacement schedules. I'm trying to find out what the replacement schedule which is permitted is so that I hopefully won't have any emergencies.

She told me I had to talk to Apria.

I told her that I had talked to Apria, and that Apria gave me different answers every time I spoke with them. I asked if Apria was following the Medicare replacement schedule. Well, they don't determine that, I would have to talk to Apria about that.

I told her I had talked to Apria about that, and that Apria told me that what I was allowed was determined by my insurance. (We'll just skip over the fact that Apria tells me something different each time I talk to them, which must mean my insurance plan is changing every time I talk to Apria.) According to Apria, I must talk to my insurance.

I have talked to my insurance, Aetna. Aetna informs me that they just administer the benefits program of my husband's employer. They do not determine what those benefits, or the replacement schedules are. I have to talk to Human Resources and the Benefits Department of my husband's employer.

So now I am talking to the HR&BD of my husband's employer. And she tells me that I have to talk to Apria about the schedule.

I told her that she was running me in circles. That Apria has told me to talk to Aetna and Aetna has told me to talk to her, and now she's telling me to talk to Apria, and that I do not like being run in circles, because if, on her instructions, I go to Apria, they will tell me I have to talk to Aetna, who will tell me I have to talk to her.

I told her I wanted, in writing, what the replacement schedule for all CPAP equipment was. I wanted it on Company stationary, and signed by the Benefits Department, and countersigned by Aetna.

She said she'd get back to me on Friday....

Kiralynx · Post by **Kiralynx** » Thu Apr 16, 2009 1:17 pm

Kiralynx · Post by **Kiralynx** » Fri Apr 24, 2009 3:22 pm

I forgot to post the final chapter in this.

The HR representative got back to me.

Aetna and Apria follow Medicare guidelines for replacements.

If I want insurance to cover anything, I must allow Apria 5-7 days to order something.

Apria is not required to have any kind of emergency supplies on hand, nor are they required, in an emergency, to overnight something to me. (I wonder if an oxygen patient would be told that?)

I cannot be reimbursed for anything which I buy out of pocket.

Remind me to have an extra mask, hose, and machine on hand at all times.

JimIllinois · Post by **JimIllinois** » Fri Apr 24, 2009 8:25 pm

An interesting thread.

But, I'm wondering about the machines. Is there an allowable minimum replacement time for them? Are they allowed to be replaced every xx years (paid for by insurance), or are they expected to last forever?

Nothing wrong with my machine, it's still pretty new, but it runs 7+ hours a night 365 days a year, it gets knocked around every month when I travel, and it can't last forever. A spare would be nice.

Portageegal · Post by **Portageegal** » Sun Apr 26, 2009 7:11 am

So glad to see the schedule. The jerks that I talked to said that I had to wait 6 mos. for a filter. I use disposables which acorrding to this is 2 per month. I will call them tomorrow a.m.

Kiralynx · Post by **Kiralynx** » Sun Apr 26, 2009 7:30 am

JimIllinois wrote:An interesting thread.

But, I'm wondering about the machines. Is there an allowable minimum replacement time for them? Are they allowed to be replaced every xx years (paid for by insurance), or are they expected to last forever?

Nothing wrong with my machine, it's still pretty new, but it runs 7+ hours a night 365 days a year, it gets knocked around every month when I travel, and it can't last forever. A spare would be nice.

I haven't been here long enough to consider replacing a machine, but I did know that i wanted a back-up one! I was able to find one at CPAPAuction.

My brother-in-law has been on CPAP for some time, and I believe got a replacement at 5 years.

Kiralynx · Post by **Kiralynx** » Sun Apr 26, 2009 7:32 am

Portageegal wrote:So glad to see the schedule. The jerks that I talked to said that I had to wait 6 mos. for a filter. I use disposables which acorrding to this is 2 per month. I will call them tomorrow a.m.

Yes -- and I was told I could have a new hose every month, but could only have nasal pillows every three.... gotta love consistency. Might consider it if I saw any!

AprilZer · Post by **AprilZer** » Wed Jun 03, 2009 2:47 am

I think some of those information is really handy .,I think this things really helps me.,

_________________
Aprilaire

twokatmew · Post by **twokatmew** » Sun Jun 14, 2009 3:55 pm

JimIllinois wrote:An interesting thread.

But, I'm wondering about the machines. Is there an allowable minimum replacement time for them? Are they allowed to be replaced every xx years (paid for by insurance), or are they expected to last forever?

Nothing wrong with my machine, it's still pretty new, but it runs 7+ hours a night 365 days a year, it gets knocked around every month when I travel, and it can't last forever. A spare would be nice.

My DME told me that Medicare will only cover a new machine if the existing machine is broken beyond repair. ...All the more reason for me to have gotten the Elite II instead of the Escape!

SaltLakeJan · Post by **SaltLakeJan** » Sun Jun 14, 2009 4:37 pm

Hi Kira,

If you haven't had an answer for your Medicare Jurisdiction, it is:

Jurisdiction C (South/Southwest)
CIGNA Government Services
P 0 Box 20010
Nashville, Tenn. 37202
Phone: 866-238-9650
http://www.cignagovernmentsevices.com

Covers, Arkansas, Colorado (go figure) Florida, Georgia, Louisiana, etc. etc.

I have had a headgear for 3 month, In my region Medicare allows a replacement every 6 months. Mine is for F&P Zest Mask, and just has a few straps. It is ragged after 3 months. I will probably have to buy two, before Medicare will allow replacement for one.

Good luck in getting your replacements.

Jan

Kiralynx · Post by **Kiralynx** » Wed Jul 15, 2009 8:54 pm

SaltLakeJan wrote:Hi Kira,

If you haven't had an answer for your Medicare Jurisdiction, it is:

Jurisdiction C (South/Southwest)
CIGNA Government Services
P 0 Box 20010
Nashville, Tenn. 37202
Phone: 866-238-9650
http://www.cignagovernmentsevices.com

Covers, Arkansas, Colorado (go figure) Florida, Georgia, Louisiana, etc. etc.

I have had a headgear for 3 month, In my region Medicare allows a replacement every 6 months. Mine is for F&P Zest Mask, and just has a few straps. It is ragged after 3 months. I will probably have to buy two, before Medicare will allow replacement for one.

Good luck in getting your replacements.

Jan,

OK, I was just looking something else up and found your response. <g> It came in while I was at the Historical Novel Society Conference, which is probably why I missed it.

Thanks for the info. I am not YET under Medicare, but was mainly looking for their schedules since so many insurance people follow them.

Still, I will file this in my folder of useful information, because I will doubtless need it... and I hate having things in places so safe even I can't find them.

Thanks again!

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Mask	Humidifier