new masks how often??

sleepyred:

i have BCBS also, and i think the key there is the phrase "medically necessary." does the doctor have to write a letter of medical necessity when something breaks/no longer is useful for whatever reason? A few years back i had a very nasty accident where i had to wear an orthopedic shoe that my orthopedist provided. i think my orthopedist finally figured out that i'm not paying the bill for that one--BCBS wouldn't pay because doc didn't write letter of medical necessity. so make sure you don't get stuck with a bill because of fast and loose language. on the other hand, my DME working through BCBS was pretty generous and seemed to think BCBS would pay for a lot.

Caroline

Caroline - good point! I'll ask that when I go in for my appt. If something breaks unexpectedly, I can get that letter pretty fast. My doctor has a wonderful staff.

My insurance company is Aetna, and they follow the Medicare guidelines. The Aetna policy at http://www.aetna.com/cpb/data/CPBA0004.html says

Note: Aetna follows Medicare DMERC rules with respect to the usual medically necessary quantity of supplies for positive airway pressure devices. See DMERC Policy on Continuous Positive Airway Pressure System (CPAP) and on Respiratory Assist Devices at the TriCenturion, LLC DMERC website, at http://www.tricenturion.com/content/lmr ... nt_dyn.cfm

Follow the link to tricenturion, and pick the CPAP document. There's a lot of interesting data there. A new mask every three months, two sets of nasal pillows per month, and something new coded as A4604.

A4604 describes tubing used with a heated humidifier which and has a heated wire running the length of the tubing. It is designed for use with a positive airway pressure device and a non-invasive interface – i.e., nasal or face mask, nasal cannula, or oral interface.

Seems the Aussie heated hose now has its own code, so it might be reimbursable, as of 1/1/2006.

My BC/BS HMO allows for mask replacement every 3 months. I have noticed that the cushion (Ultramirage FF) tends to lose its "stuff" after about 3-4 months--increasing leakage, etc. (Probably due to my oily Italian skin--even with daily washing and using a cloth cushion-cover!!)

Since I can get the whole kit-and-kaboodle, I do. Ever since I've been consistent in changing out, my leak rate has stayed down. I can't imagine using the same cushion for a year or more!! Even if I had to pay for it, I'd still replace the cushion regularly.

Grant