Total Newb seeks commentary.

OK - recently diagnosed with an AHI of 56, titrated to a pressure of 9. I'm now dealing with local DME's and trying to get this all right the first time. I'm an engineer/IT person by trade and temperament, and hence highly motivated to take the most active role possible in my own treatment. To me, this means having a unit with the greatest number of options available, as well as data capability and software so I can self-monitor in exacting detail. I mentioned this to them, and they seemed a little startled that I was so eager to dive into the nerdiest of details. Evidently, I'm not what they're used to dealing with.

Anyway, after much reading, I've fixated on the ResMed S8 Autoset II. I actually have one on loan from the first DME I went to. In this case, "on loan" means that I was comparing this and a RemStar M-Series while there in the office, and they didn't have any ResMed units to send me home with. This may have been a stroke of luck, however, since they were trying to tell me that I would not be covered for the AutoSet, and would wind up with an Elite. Today, I called my insurance provider with the CPT code for the AutoSet, and they pleasantly informed me that the coverage was the same. My response upon hearing this was to find out what other DMEs near me were 'in plan' and begin making phone calls. When doing so, I gave the customer service reps no other option than to quote me pricing on the unit I want. They did so without complaint.

So - how do I play it when I take back my loaner? Based on the identical CPT codes, will my provider cover me for an AutoSet as well as an Elite? Do I explain to DME #1 that the CPT code is the same, and politely demand the unit I want? Do I return everything and jump to whoever is most accommodating? The staff were pleasant at the first place, and it's very close to my office, so I'd like to deal with them if I can (preferably without alienating them.)

Any and all comments are welcomed - from "tell them to go to h*ll," to "dude, you're thinking WAY too much about this."

Thanks in advance.

I created a similar thread yesterday, so I will chime in here to track your progress as well.

My insurance situation is exactly the same as yours, but my first DME flat out said he would not sell me the Elite II OR the Autoset II because it cost him too much, which of course means "I don't make enough money". Since the insurance appears to reimburse at the same rate for a basic compliance model vs a fully data capable one it sounds like the most flexible DME is the one willing to work on volume and/or future sales of supplies/masks rather than make their bucks on the initial machine.

Yeah.

Fortunately, my attitude is anything but passive. The way I see it, I'm the customer, it's my money, and if they want it, they can bloody well do what I want. Never having been through it, however, I'm wondering if this is the correct way to proceed.

What exactly does your prescription call for? The DME has to match your prescription with equipment, and that is a LOT easier if your doctor has stipulated APAP + accessories, than if he simply scripts CPAP with a static pressure. There are a lot of reasons to have APAP. pressures do change with time or sleeping position, and the ability to monitor data helps you take an active role in therapy, not to mention the positive feedback that reinforces compliance. Rather than hash this out with a DME, it is the script from your doc that is the basis to ensure you will get the functionality of an APAP with data. If you feel your script doesn't do that, and you experience problems getting the equipment you want, I would suggest declining equipment (keep the loaner) until you can get a better prescription. In general, I have not found the DME I work with to be at all difficult.

Excellent advice. The script (as far as I know) is for CPAP, humidification, and specifically C-Flex. I explained to the tech at the DME that in my opinion, ResMed's EPR technology has the same goal as C-Flex, so I didn't want to be tied down to Respironics. She was OK with that, and I was already closer to my goal.

If they prove intractable, and I need to go back to the doctor for a new script, how do I go about convincing them? Why should they accommodate me on the grounds of what must, to them, seem like whimsy?

Cavallo wrote: I need to go back to the doctor for a new script, how do I go about convincing them? Why should they accommodate me on the grounds of what must, to them, seem like whimsy?

When I was where you are at in my cpap journey,
I wrote a letter to my PCP doc.
I firmly explained that this therapy was my life.
I was getting educated and I was going to be in control.
I needed this machine __________________ and
I needed a Rx written w/that exact wording.

His PA called back in an hour and said the Rx was at the front desk.

This is your therapy.
You will be in control.
Be sure to get a physical Rx, in your hand.....
no copies...no "we'll fax it".....no "we'll call it in"...
in your hand.

It's your life.
It's my life.

Cavallo wrote:Excellent advice. The script (as far as I know) is for CPAP, humidification, and specifically C-Flex. I explained to the tech at the DME that in my opinion, ResMed's EPR technology has the same goal as C-Flex, so I didn't want to be tied down to Respironics. She was OK with that, and I was already closer to my goal.

If they prove intractable, and I need to go back to the doctor for a new script, how do I go about convincing them? Why should they accommodate me on the grounds of what must, to them, seem like whimsy?

First of all, I don't think you will need to plead your case to your doctor. Most simply modify the script on request. If you do need to explain this, be prepared. Here are some suggestions:
List the reasons you feel APAP with exhalation relief and data is appropriate for you
Explain that without a specific prescription, the DME will dispense the cheapest solution that lacks those features. Unlike your doctor, the DME technician has a clear fiduciary commitment to the profit-line of DME corporation, in other words when insurance income is fixed, they maximize profit by cheapest equipment possible, while complying with the doctor's prescription. You DO get what you pay for.
Explain that YOU are willing to invest your time to collect data, and your money to purchase the necessary software and card-readers that are not covered by insurance.
APAP allows you to monitor your therapy and if results are not consistent with expectations, it can be used to verify or change titration without the expense of another sleep study.
It allows your doctor and you to quantitatively actually measure your progress and make adaptations.
Without data, XPAP is like trying to diagnose and treat a broken bone without Xray (use analogy of your choice).

I'm sure you have plenty of reasons of your own to add.

Here's what I just sent to my Doctor's office;
——————————————————————————
Dear Dr. XXXXXXX;

First of all, I wanted to thank you, and all the staff at XXXXXXX I've dealt with so far.
From my initial consult, to my sleep studies, even to just calling on the phone with
simple questions, everyone has been pleasant and helpful. This really makes a diagnosis
of severe obstructive sleep apnea much easier to take.

Since my diagnosis, I've taken steps to educate myself about OSA, and my treatment
options. I take this diagnosis very seriously, and am highly motivated to make this work.
I've had an initial visit to my local DME, and it went reasonably well. After comparing
models of CPAP/APAP in their office, they have given me a ResMed S8 Autoset II unit as
a loaner for a few days. They were most accommodating, particularly since the prescrip
-tion I received specified C-Flex.

While I'm grateful for the explicit inclusion of expiratory pressure relief in my prescription,
I have compared the approaches taken by Respironics (C-Flex,) and ResMed (EPR,) and
must say that I have more confidence in the details of the EPR algorithm. After research
and live comparison, I definitely think the ResMed unit would provide me with better treat-
ment, and a better ability to self monitor (with the appropriate ResScan software, which
I have already taken steps to acquire.)

Additionally, considering my lifestyle and my insurance coverage, I am firmly of the opinion
that the automatic titration feature is a better fit for me. Until recently, I have led a reason-
ably active lifestyle, including travel, which often found me asleep in a variety of situations.
I have high hopes that this therapy will be able to return me to this level of activity. I would
very much appreciate the peace of mind inherent in the notion that my machine would be cap-
able of adapting to me under varying conditions of posture, or muscular relaxation. Also, my
provider will be billed identically by the DME whether I choose the Autoset (APAP) or the Elite
(CPAP.) If a fixed amount of my money is to be spent, I prefer to get the greatest value from
it. Especially since I intend to be a full participant in this ongoing process, I'd like to know
that I have a unit that gives me the largest number of options to choose from to optimize my
own treatment, and subsequently report my success to you.

Unfortunately, the DME I've dealt with so far seemed reluctant to provide me with the Autoset unit.

I would very much appreciate it if your office would issue a new, more specific prescription
for the ResMed S8 Autoset II with Humidaire H4i Heated Humidifier directly to me. This
will give me the tools I need to deal with the DME provider, and ultimately to achieve the
very best treatment. If this presents a problem, please let me know, and I'll be happy to
make an appointment to discuss this further in person.

Thank you.

Sincerely;

Etc...

Cavallo wrote:Here's what I just sent to my Doctor's office;
——————————————————————————
Dear Dr. XXXXXXX;


Etc...

....damn, you're good.

And indeed, literally minutes after posting this, my Dr.'s office called me back to say, OK. They've written a new order, and are faxing it to me, the DME, and mailing me a hard-copy to my home address.

Thank you all for the quick responses and good advice. This place officially rocks.

carbonman wrote:

Cavallo wrote:Here's what I just sent to my Doctor's office;
——————————————————————————
Dear Dr. XXXXXXX;


Etc...

....damn, you're good.

Heh - thanks. And that's with OSA brain fog. I fully expect to be able to bend space and time once I'm better.

Anyway, I figured if I posted it, others might be able to use it as a kind of template.

good stuff right there! Glad this worked out so well.

I think that the stress of acquiring equipment induces us to forget our personal physician are our partner in this process, not the enemy. Sounds like you have a good partner.

When I first left my Primary's office, I began soliciting opinions from friends who had been through this before me. The lab and pulmonary department I picked was everybody's top choice in my area, hands down. Given the reviews I got, I'm actually not all that surprised that they're providing such excellent service. If anyone on here is from the Central NY area, I'd be happy to PM the details to them.