UGH - Swift FX Nano - Insurance Issues

Hello Everyone,

Looking for thoughts on this. So I use the Swift FX Nano - it appears that the "cushion" based on the how the mask is built is considered part of the frame and I am told from my DME that they can not bill the replacement cushion under A7032. I guess when the mask was new they were doing this until an insurance company notified them that they were fraudulent billing as this particular cushion was part of the frame. The DME contacted ResMed and ResMed confirmed that they did not receive approval to classify this cushion under A7032. As such they bill under A7034, so only once per year is allowed. My DME even said that they returned all of the parts back to the supplier as they could not sell them anyway and only order full masks now.

Anyone else have this problem? I talked to the insurance and they did not know about a specific mask, but the DME said no way they bill with that code as ResMed did not have approval to use that code...

I think I need to find a new mask if this is the case, thoughts?
Paul

So, this time I called ResMed - and yup, they said that CMS coded it as part of the frame A7034... my insurance is a bit strange as for code A7034 is every 6 months and A7034 headgear every 6 months... most interesting I think

Call Medicare; I would only believe them.
All others may have no reservations about lying to you.
I would suspect the same of the Swift FX pillows mask--for the same reason.
Logically, the part with the swivel should be the integral "mask" part.

I had the same problem with my DME and Medicare so I switched to the Eson nasal mask. Now using Quattro Air.

Do you love the mask otherwise? Or is it just an "okay" mask?

The cushion should last at least 3 months ...maybe even to 6 months when you can get a complete mask package with insurance coverage. Do you have a co pay with supplies? If so how much? Deductible?
Do the math...how much out of pocket if you just buy a replacement cushion without insurance coverage from cpap.com compared to out of pocket costs from DME using insurance.
If you love the mask and it won't take food off the table and need a replacement cushion...maybe just buy it yourself.
Heck, watch EBay...I have seen the Nano cushion offered there..new for a very reasonable price if you shop smart and watch close. Just looked...I see one for $22.99 Buy it now price and that includes free shipping...others around $33.

If it's just an "okay" mask and you just want to try something else then that's always an option but don't give up something you "love" unless you just have to.

Thanks everyone,

To me the mask is a keeper, but perhaps I will start looking around at other masks. I think I can get 6 months from the mask now so it just fits into the replacement for "frame" with my insurance. I just have a feeling that this will be recurring conversation every 6 months with my DME who is otherwise been very good. My uses the Swift FX Nasal and I just ordered her the P10 from cpap.com - her DME is horrible to work with. So perhaps I will try that mask also - then the cushion is really a cushion....

Paul

I'm on Medicare (a Medicare Advantage plan) and used the Swift FX for nearly a year and I was able to get two replacement pillows each month (although one usually lasted at least a couple of months).

What a mess. I became Medicare-eligible year before last and last year, even though dealing having to deal with a DME supplier rather than my Medical folks was a royal pain, they provided me with Swift FX Nano supplies & NEVER SAID ANYTHING ABOUT ONLY BEING ABLE TO PROVIDE CUSHIONS EVERY 6 MONTHS. It was only last month that, eventually, after numerous calls & being told various run-arounds, a supervisor called and said Medicare would only allow replacement of the entire unit, headgear and cushion, and they would only allow it every 6 months. They couldn't provide me with any proof, documentation from Medicare, or explanation. They pushed me towards a Wisp mask, that, like the ResMed Mirage, leaves a scrape on the bridge of my nose. If anyone can point me towards the Medicare decision on this I'd be very interested.

Things may have changed in the 2 years since the original post.

Alas, little has improved on the supplier side.
Assume this one is lying to you, and look for another.
If you click on the Medicare link in my signature, enter your zip code, and
look for the green "M" for the suppliers contracted with Medicare (to not overcharge you).
If none are close, expand the search radius to how far you can reasonably travel.