Question on Machines

[tresguey]

Hi, I am a new CPAP user as of yesterday. I have a few questions that I hope someone can help me with.

I did as much research as I could online and with my insurance company. I was wanting a resmed S9 autoset. From the research I did I felt this would be the quietest and easiest to breath with. I didn't even research masks. This was because I am also a SCUBA diver and know that all masks are not created equal. I was assuming that I would have the opportunity to try on a few.

My doctor wrote a generic script for a CPAP and heated humidifier with full face mask and related equipment. And sent it to Apria. When Apria called I asked if I can get the Resmed S9 auotset and was told yes. When I got there they had a Philips DS250S programmed and a mask. I told the tech that I was wanting the Resmed S9 autoset and I had called. He talked to his supervisor and she came in and she said that the Resmed auto set needed two setting numbers. And it was a advance system that my insurance would not cover. She also had the script for the doctor I had 3 years ago right before my insurance ran out. I have Healthnet now and what I was told is that they would cover 100% of all my hard equipment. So I would figure what does it matter which machine I choose. Or are you not allowed to? Do these places get kick-backs on machines they send you out with?

[Pugsy]

Do these places get kick-backs on machines they send you out with?

They might. For sure that make more money dispensing the machines like the PR S1 DS 250 which is the PR System One Remstar Plus with CFlex and it offers zero useful data. A brick. It does have a SD card which will document hours of use only.

Full data machines and/or APAP machines cost a little more at the wholesale level. So guess which one they want to dispense? The difference in price at the wholesale level is not all that much but $50 or $100 here and there add up to a big chunk change if they dispense 100 of them.

With machines like the DS250 or the ResMed Escape ....you only get hours of use data. Nothing else.
Nothing to even monitor leaks with.

You might want to read this....http://maskarrayed.wordpress.com/

[jamiswolf]

Tresguey wrote: My doctor wrote a generic script for a CPAP and heated humidifier with full face mask and related equipment.

I'm no expert on the insurance/dme aspect of thing...but it seems this is the problem. If your Doc writes a specific Rx, then the dme has to follow it. If he writes a generic Rx...then the DME gets to decide.

Do not except the PR machine since it is a PLUS which translates into a data-less machine. If you desire to be pro-active and monitor your data...you'll need a machine that provides data.

Regarding auto VS non-auto cpap. Not that big a deal. If you were titrated for pressure...then an auto machine isn't really needed. But if you can talk your Doc into writing Rx for an auto...then so much the better.

Oh, and yes, the DME makes money on the deal. How else are they going to stay in business. There's a standard code for most cpap machines and if they can get you to accept a low end machine (Like the plus) then they make even more money.
J

[Mary Z]

Not everyone needs an AUTO machine. They serve a great purpose in the right instances. Usually you need to fail CPAP therapy before you move up to another mode of machine. You got bad advice from the person who said you could have the AUTOset without a specific prescription and it does need two pressure requirements. Without a range of pressures the DME would not be able to program the machine.
I find CPAP to be very comfortable. Give it a real chance, please, before demanding an AUTO. This is a prescription device and the choice of machine modes determined by your doctor. If you are determined to have an AUTO and cannot get it through insurance, buy a used machine OOP.
If you are still unhappy after you try the CPAP, talk to your doc. Or talk to him now about a different prescription.
Good luck. I know the forum is heavily weighted toward AUTO machines. CPAP is not second best.
I don't know if the DME gets "kickbacks". I doubt that, but they are legitimate businesses and if they didn't make money they would not stay in business. Medical equipment is very expensive.
I agree data capable is a must.
Good luck.

[Pugsy]

APAP machines..like the PR System One Auto CPAP with AFlex and the ResMed S9 Autoset can be set to CPAP mode to satisfy RX specifics. They are 2 machines in one.

You may or may not be one of those people who do better with APAP. No way to know that at the moment but it is nice to have it available. Is it critical? Probably not but there are instances when APAP mode is useful..like if your OSA happens to need more pressure during REM sleep or if you roll over onto your back.
This is a very common occurrence. I had it happen to me. During REM sleep I sometimes need a pressure up near 18 cm....other times I can get by with 10 or 11 cm. I sure don't want to use 18 cm all the time and that would be what I would have to do without APAP if I wanted to prevent those events. My other choice would be to use 10 or 11 cpap and let those 18 cm needing events just happen. Obviously not what I would want either.

If you really want the S9 Autoset...shop around with DMEs in your network to see if one will supply you one. They could set it in CPAP mode at your prescribed pressure.

For sure don't take receipt of a machine with no useful data.

[tresguey]

Thanks for all the advice on the machine. I just want to make sure I get the best treatment I can as I am very proactive.

Is there a way I can try on masks, or am I just going to do a trial and error type of situation every 6 months?

[jamiswolf]

Is there a way I can try on masks, or am I just going to do a trial and error type of situation every 6 months?

Talk to your DME. The manufacturers sponsor an exchange program. If your mask doesn't work...bring it back and try another one at no cost to you or the DME.
J

[StevenXXXX]

Is there a way I can try on masks, or am I just going to do a trial and error type of situation every 6 months?

Most DME providers participate in the 30 Day Trial Period for masks until you find one that works.

[robysue]

tresguey,

First jamiswolf is right: Do NOT accept delivery on the PR S1 DS 250 (aka the System One Plus) machine. It records only usage data.

Second pugsy is spot on in two things: (1) Read and re-read JanKnitz's blog. The blog entry you want in particular is What you need to know before you meet your DME. (2) APAP machines can be set to run in CPAP mode, but a CPAP machine cannot be set to run in APAP mode.

As JanKnitz points out, most insurance companies pay for the CPAP/APAP machine by HCPC code and the code for all CPAPs and APAPs is E0601. There are some enlightened DMEs realize that providing their new customers with an efficacy data machine can lead to to good things---including better patient compliance and better customer loyalty, both of which are good for the DME's bottom line in the long term.

So my advice on what to do next is this:

1) Call your insurance company TODAY or tomorrow at the latest. Find out directly from the insurance company whether they pay for you equipment by HCPC code. Also find out exactly how they pay for your equipment: Is it a capped rental (i.e. a "rent to own" deal)? Is it an outright purchase? How much is your copay? Weigh all this into the decision of what equipment to get and where to get it: If you have a large deductible, you may find that it will be cheaper to buy the machine on-line from a place like our host, cpap.com, than it is to go through Apria and your insurance.

2) While you are talking to your insurance find out whether there are other in-network DMEs that you can use. Tell them that Apria told you one thing on the phone and then when you got there, they'd set up a different machine altogether for you and that you would really rather not do business with them.

3) Once you have a list of in-network DMEs that work with your insurance, start calling them and asking questions. Be polite, but firm, that you are not interested in accepting a PR System One Plus (PR S1 DS 250) or a Resmed S9 Escape since these models do not record full efficacy data. You may want to consider accepting a PR System One Pro (PR S1 DS 450) or a Resmed S9 Elite since these straight CPAP machines do record full efficacy data. They are not quite so flexible since they cannot later be set to an Auto range in case you need a short run on auto titration to confirm or tweak your prescribed pressure levels, but you still have the data you need for optimizing both your comfort and the efficacy of your therapy. You may find that smaller, more local DMEs or DMEs that focus on providing CPAP supplies may be more open to the idea of providing you with an S9 AutoSet or a System One Auto.

Best of luck

[tresguey]

After reading that thread a few times I called Healthnet they informed me that they will cover the E0601's and that I would have to call my medical group to find out which other DME's I have in network. When I called them they said Apria was the only in network DME the medical group went through.

So I will try and play a little hardball with Apria.

[jamiswolf]

After reading that thread a few times I called Healthnet they informed me that they will cover the E0601's and that I would have to call my medical group to find out which other DME's I have in network. When I called them they said Apria was the only in network DME the medical group went through.

So I will try and play a little hardball with Apria.

I'd start by talking with your Doc and asking him to write a more specific Rx for the machine you would like.
J

Edit: One other option I thought I'd mention. Forget about your DME and buy a machine from the Craigslist or internet "black market". Eliminate 13 months of co-payments. I'm quite sure you could find a data-capable auto cpap for under $1000 new. I'm using a used BiPap machine I picked up for $100. Had one year of use on it and works like a charm.

[NateS]

Thanks for all the advice on the machine. I just want to make sure I get the best treatment I can as I am very proactive.

If you are very proactive you have come to the right place - cpaptalk.

If you are very proactive you are not going to be happy with a machine that doesn't enable you to observe your progress in therapy and see possible areas for improvement or adjustment if necessary.

If your machine does not provide you with this information then it will obviously not provide your doctor or anyone else with that data either. How will your doctor be able to answer your questions? How will your doctor know how effective your therapy is and/or whether to prescribe any changes or adjustments? And if at some point, your doctor wants to have you take a second sleep study, how will he/she justify the expense to the insurance company?

Well-informed is well-armed.

Stand firm.

Best wishes, Nate

[archangle]

See if there is more than one DME who is "in-network" for your insurance. If so, you should try another DME if you feel that one lied to you about them being willing to give you an AutoSet. Let the DMEs know you are looking at multiple DMEs if you have that option.

An AutoSet can be used even if the prescription calls for a single pressure. It simply has to be set up for a single pressure. The insurance will probably pay for it, but the DME probably gets paid the same amount for any CPAP/APAP machine, so the DME has a big incentive to give you the cheapest machine they can.

Craigslist is a crap shoot. I've seen good stuff for sale cheap, but it's mostly people wanting more for obsolete junk than you can buy it for new online. They were screwed into paying double price by a DME, presented with a fantasy bill that's twice what insurance will pay. Used medical equipment with no warranty is not worth a fraction of what a new machine with local support costs.

I have found good equipment at good prices on Craigslist, but it usually takes weeks or months of watching the local ads. On the local CL, I haven't seen anything at a halfway reasonable price in months.

Cpap.com, who hosts this site sells equipment at excellent prices, but your insurance probably won't reimburse you for buying from them. Check your reimbursement rates. Online may not be that much more expensive than local after deductibles and copays. You may be renting the machine for over a year, so you may pay more than one deductible if you buy locally.

If you decide not to fight for an auto machine, the S9 Elite is about as good as the AutoSet except for no auto. The Elite and AutoSet are much better than S9 Escape or S9 Escape Auto. Be careful that someone doesn't try to scam you with an S9 Escape Auto instead of AutoSet. There is no "S9 Auto" machine. Be sure to say "AutoSet" and look for the model name next to the on button.

Philips Respironics System One (PRS1) are roughly equivalent to the S9 machines. PRS1 Auto and Pro are MUCH better than the PRS1 Plus. PRS1 may be cheaper than S9 online.

[tresguey]

Well I called the DME and explained my situation. Told them that I called Healthnet and my insurance group. They both said that my insurance would cover that machine. After being told that no one could even find my prescription and had nothing from my current doctor, but they did have a prescription from my doctor in 2009 and based my machine setup with that information. That test was the deal where you put something on your finger at home for a night. I did not do a sleep study. I told them that and said that whatever setup is on the machine they gave me yesterday may not be correct for me and asked if it can actually harm me. I was told no and they would have a supervisor call me Monday. Also I was told that there are different codes for the autoset machines, which I am sure the are not telling the truth.

Any thoughts on this?

[Random Coolzip]

My first post here!

First, thank you all for being here and providing so much useful information and links to other resources. Since I was diagnosed in January and titrated two weeks ago, I have been reading this forum like crazy, trying to learn as much as possible.

My insurance company referred me over to Apria and, based on what I've read here, I feared it was going to be a fight. I was armed with the facts and when they called a few minutes ago to schedule an appointment locally, I asked them if I could pick my machine. The operator said, "No, you've been specified for a REMStar ..." I asked if the prescription specifically called for one, she said, "No ... it specifies a CPAP ..." so we went a few laps on that point Then I asked about the humidifier and heated tubing, and she said that wasn't included either. I knew this was all ball-shoi so I hung up and called my insurance company.

They were great and reconfirmed what I was entitled to and suggested we try another DME. We're heading that way now and I anticipate smoother sailing. Just wanted to say THANK YOU to all of your for your generous contributions that shortened my learning curve infinitely.

Chris