Insurance coverage for "cushions". Confusion.

DMEPs and patients seem to have confusion over insurance coverage for some CPAP supplies. One example is the Mirage FX system. Some carriers allow reimbursement for TWO nasal cushions per month.

According to ResMed and other websites, that triangular piece of the Mirage FX which fits over the nose is properly called a cushion, not a mask:

LINKS: http://www.easybreathe.com/Mirage-FX-Ma ... p3581.html and http://www.resmed.com/us/en/consumer/pr ... ge-fx.html and http://www.sleepapnea.com/sleep_patient ... ement.aspx

So, does this mean that an insured is eligible to receive TWO Mirage FX "masks" per month because they are called "cushions" ? Has anyone defined what is a "mask" and what is a "cushion" ?

Replacement parts are available separately although they are also part of the complete mask. This is your complete mask: https://www.cpap.com/productpage/Resmed ... dgear.html
This is the replacement cushion: https://www.cpap.com/productpage/Mirage ... shion.html
You can get to the replacement parts by clicking on the Replacement Parts button from the complete mask.

Insurance typically covers one complete mask every 3 or 6 months, and one replacement cushion monthly, or two sets of replacement pillows every month (for a pillows style mask such as the Swift FX).
Edit: A replacement mask at 3 months may be for a mask that is complete except for headgear, to add to the confusion.

Yes, but note that Medicare, for example, allows TWO cushions per month. That is actually two masks per month. What is the official and accepted definition of a "mask" ?

Physician wrote:Yes, but note that Medicare, for example, allows TWO cushions per month. That is actually two masks per month. What is the official and accepted definition of a "mask" ?

A cushion is not a mask, it is only PART of a mask. The cushion is the soft silicone or gel part that comes apart from the frame. A mask is the frame AND cushion together. I don't know of any insurance (or medicare) that would pay for a new mask every month, let alone two. The hard frame of a mask lasts a longer than that. I have been using cpap for 2 years. I am still using my first two masks. I only replace the cushions.

Physician wrote:What is the official and accepted definition of a "mask" ?

Assuming you meant a total complete mask with no missing parts.
For Medicare it may be the inclusion of the headgear and they only allow 1 per 6 months for headgear billing.

Now they also say "mask" 1 per 3 months but it isn't supposed to necessarily included headgear. So sometime DMEs will do a complete mask that includes headgear but they won't get paid for the headgear at 3 months from Medicare.
DMEs normally list each mask part separately for billing purposes despite the fact that there may only be one package. Insurance companies and Medicare accept it and expect it.

Sometimes a cushion isn't replaceable separate part. To find out which billing code pertains to which mask part often we have to go to the mask manufacturer as they also supply the individual HCPCS billing codes for each part. So it may be confusing as to which code below a particular part goes under.

Y'all are lucky; my insurance plan covers exactly no masks, cushions, headgear or even filters. They paid half of my machine and humidifier only. I'm on my own for the rest.

To confuse matters even more fully, please note the terms "mask" and "interface" are used interchangeably.
Apparently, technical writers did not produce this document, as tech writers strive for clarity,
unlike lawyers . . .

Pugsy, your post seems to conflict with these links in the start post:

LINKS: http://www.easybreathe.com/Mirage-FX-Ma ... p3581.html and http://www.resmed.com/us/en/consumer/pr ... ge-fx.html and http://www.sleepapnea.com/sleep_patient ... ement.aspx


The Mirage FX has a cushion which surrounds the nose, and two cushions per month are permitted under, for instance, Medicare.

I never said Medicare didn't allow 2 cushions per month for the Mirage FX...that would be HCPCS billing code A7032 which clearly states 2 per month. That would be "cushions" and not complete mask setups which includes frame/headgear and cushions..

I guess I misunderstood your question as to "what constitutes a full mask" as in meaning what is needed for Medicare to deem it a full mask setup as opposed to some replacement part. I never meant to imply that 2 per month weren't allowed...I was only trying to clarify what constitutes a full face mask setup per the way the gov't looks at things which as usual ...doesn't make much sense sometimes.

The screen shot I posted was taken from a Medicare/US gov't paper. It's used by pretty much everyone. Standard cpap replacement schedule.

I couldn't get your link to work but I found this
http://www.resmed.com/content/dam/resme ... sories.pdf

Page 2 shows which codes goes with what mask/parts for initial setup vs just a replacement cushion/pillow or the frame plus cushion. The prices are 2012 prices but the overall replacement numbers and schedule haven't changed.
Many DMEs won't stock A7034 which is frame plus cushion without headgear since Medicare won't pay for the headgear at 3 months which is what medicare allows for for A7034. They won't tell you that though. They just will tell you "your insurance (Medicare) only pays for 1 mask every 6 months".

So I guess I apologize and I apparently tried to answer a question I thought you had instead of what you had.
I will leave the schedule..it's a good schedule as I got it from a fairly current government paper.

Pugsy wrote: I guess I misunderstood your question as to "what constitutes a full mask" as in meaning what is needed for Medicare to deem it a full mask setup as opposed to some replacement part. I never meant to imply that 2 per month weren't allowed...I was only trying to clarify what constitutes a full face mask setup per the way the gov't looks at things which as usual ...doesn't make much sense sometimes.

From the multiple posts from "Physician", I would assume this person is having trouble understanding the difference between a mask and a cushion.

Thank you, Pugsy. You write very well. Rest assured, my CPAP buddies and two DMEPs were similarly confused.

I can understand some DMEP's being confused.
For some locations, it seems to be a requirement to "work" there.

chunkyfrog wrote:To confuse matters even more fully, please note the terms "mask" and "interface" are used interchangeably.
Apparently, technical writers did not produce this document, as tech writers strive for clarity,
unlike lawyers . . .

That should be "Patient Interface" which would include everything needed to breath using the machine - interface between the patient and the machine.

chunkyfrog wrote:I can understand some DMEP's being confused.
For some locations, it seems to be a requirement to "work" there.

i think the sole whole purpose of this thread is to cause more disinformation spin for apria