Medicare and Masks

Hi All.

I have a question about Medicare CPAP supply coverage.

I have been using CPAP for 17 years and have been on Medicare for the last 2 1/2 years.

I have ordered my usual Nasal mask from time to time with no problem.

But My Doc recently wanted me to use a FFM when necessary due to some congestion.

When I spoke to the DME (Crapria), they said Medicare required them to have a Rx specific to a FFM, and they would not accept my standing order for a "Mask" from my Doc.

Anyone heard of this before?

Are they right, or jerking me around?

Thanks.

pratzert wrote: ↑

Sun Dec 17, 2023 5:37 pm

jerking me around?

This gets my vote.

Sounds like big jerk to me. Mask prescriptions should simply state "Mask of patient's choice."

pratzert wrote: ↑

Sun Dec 17, 2023 5:37 pm

When I spoke to the DME (Crapria),

First get rid of them.

You didn't mention if you have the Original Medicare or some disAdvantage plan but I have OM and use a mail order and change masks quite often.

Have your Dr. write the script to say "Mask of Patients Choice" and get a copy for your records along with your sleep study results.

Using a mail order like Verus or Aeroflow they will contact your Dr to get the info they need or want.

Good Luck.

pratzert wrote: ↑

Sun Dec 17, 2023 5:37 pm

Hi All.

I have a question about Medicare CPAP supply coverage.

I have been using CPAP for 17 years and have been on Medicare for the last 2 1/2 years.

I have ordered my usual Nasal mask from time to time with no problem.

But My Doc recently wanted me to use a FFM when necessary due to some congestion.

When I spoke to the DME (Crapria), they said Medicare required them to have a Rx specific to a FFM, and they would not accept my standing order for a "Mask" from my Doc.

Anyone heard of this before?

Are they right, or jerking me around?

Thanks.

I switched from the nasal pillows to a nasal mask to a hybrid full face mask, but timing was always just before I received an email telling me I was eligible to reorder supplies, then I’d called the DME, AdaptHealth, with the updated mask style I was using. It was only when I switched from the nasal to full face mask was I asked when my last doctor appointment at the sleep clinic. I indicated it was within 30 days for a follow up appointment and that the nurse practitioner and respiratory therapist agreed to switching my mask. The DME updated the info and placed my order for updated supplies. No script was requested and I am on Medicare as well.

Ebonyeyez wrote: ↑

Sun Dec 17, 2023 7:19 pm

No script was requested and I am on Medicare as well.

The reason they ask who the Dr is they will get what they need/want directly from the Dr.

Not only do they need a script (equipment order) but notes from the Dr indicating you are benefitting from the use of cpap.

BTW... I am on "Original/Traditional Medicare".

I am not currently seeing a Sleep Doc. My Primary care Doc said he will write an Rx for whatever I need.

But he is not a sleep Doc/Pulmonologist, and I am sure he is not extremely well versed on the ins and outs of the APNEA world.

He does mark it in my chart occasionally that I use CPAP and benefit from it.

My old sleep Doc went to jail for selling drugs. Lost his license and jail time for 2 years.

I guess I should find another sleep Doc.

Unless you are having problems there really isn't an urgent need to find another sleep doc.
I haven't seen one since Aug 2009 and I am doing just fine and my PCP writes the RX for whatever I want or need without question. I don't really care that he doesn't understand all the ins and outs of cpap therapy. I can manage it myself quite nicely. Now if I ran into major problems that I couldn't handle then maybe I would go find another sleep doc.

Thank s for all of the replies.

So everyone is in agreement that the DME is full of it, which is no surprise.

Like Pugsy, I haven't seen a great need to see a sleep Doc, as I have been on CPAP therapy long enough to be able to handle "most" problems.

So far, I have not had anyone (Medicare) say they want a more updated sleep study. (Last one was in 2017).

Medicare doesn't really want to require anything that they have to pay for....so Medicare is actually fairly lenient for those of us already on cpap because we have already met the basic requirements.

Now....suppliers will often make up their own in house rules about something and then blame it on "your insurance requires so and so"...which is legal for them to make their own in house rules but when they start blaming someone else instead of just owning up to their own in house rules....that's where the lying begins and where I have a problem with them.

Reminds me of the old joke.."how do you know a DME is lying? Their lips are moving"

Medicare doesn't care what mask you want to use. They only care that you use whatever you choose.

A generic RX of "mask of patient's choice" will satisfy Medicare's requirements.

Pugsy,

Yes, I've heard that one many times.

And Crapria is the Master of the Art of Lies.

I was given a name of a DME that is close to me that I am going to call to see if I can start giving them my business.

One of the sad facts about DME's, is that they consider the Doctor's as their customers, and not the patients.

Both nasal and FF masks are the same HCPCS code, so Medicare doesn't care which you get.

But there could be two reasons that Crapria is giving you a hard time:
1. You may have received a complete mask with everything (cushion, frame, and--most importantly, the damn strap) within the past six months. That means Crapria can't part out the mask to get Medicare to pay for the strap, which Medicare will only replace every six months (and it's the part that usually wears out FIRST!).

2. Your original order may have specified the mask, and while Crapria often plays bait and switch with the machine and mask parts, they are buckling down on the prescription.

Your regular doctor, who is not well-versed in sleep medicine, can simply write "mask of patient's choice". That should take care of the prescription issue. And you can buy the damn strap on Amazon or e-Bay if it's too soon to get Medicare to pay for it. Crapria buys mask fitting packages from the manufacturers for one low price, but they pad their profits by billing each part separately. So my guess is that they are stalling to avoid having to lose the revenue from the strap, when they would still make more parting everything else out and just giving you the strap.
So very, very glad I don't have to deal with Crapria anymore!

pratzert wrote: ↑

Mon Dec 18, 2023 10:29 am

I haven't seen a great need to see a sleep Doc, as I have been on CPAP therapy long enough to be able to handle "most" problems.

pratzert wrote: ↑

Mon Dec 18, 2023 10:46 am

I was given a name of a DME that is close to me that I am going to call to see if I can start giving them my business.

A mail order DME should work just fine for you then.

The DME will normally coach the doc on what is needed so you should be good. Any doc can do the paperwork.

Thanks again everyone.

It's been about a years since last got a mask, so Crapria can get away with parting out an entire mask.

Most unfortunately, I don't have a copy of the original Rx for my supplies, otherwise, it would be an easy matter to walk with it wherever I wished.

Another thing that was floating around, was that the Rx "Expires" after a year and a new Rx had to be written every year.

Is that true.... or not ?

Another thing that was floating around, was that the Rx "Expires" after a year and a new Rx had to be written every year.

Is that true.... or not ?

It seems to be true according to recent posts. It may be state dependent.