How to get the ball rolling...

[FrankNichols]

I am new here and to Apnea in general. Just finished my second sleep study (titration) and I will be visiting the doctor this week to get the results and the script (hopefully).

I apparently have both OSA and CSA and during the titration study the technical was unable to tune out all the Centrals, and tried to find a balance (She asked me not to tell the doctor she said so because it is not her place to interpret the study, but she said I was throwing a LOT of CSAs). The doctors comment after the first study was that I had severe OSD. I trust him.

Now, I am trying to prepare for the next meeting where I am assuming the CPAP machine will be in my future and I have a few questions before I meet with him.

Background:

I am 66 and have Humana Medicare Gold PPO, which apparently pays 80/20 with 0 deductible (if I am reading the plan correctly) for the DME if the equipment is purchase from an in network DME supplier which it will be - the closest to me is Apria. In my titration study we settled on the AirFit F10 and BiLevel CPAP at high pressure (as high as she could get it without the F10 leaking too much) or a CPAP at lower levels, she wasn't sure which way the doctor was going to lean, it was a balancing act between OSAs and CSAs.

I also understand (I think) that there will be a 30 day compliance test, where I use a device for 30 days and then the doctor determines if I used it and if it was helping. If both are true, I will then get a pre-authorization to buy or rent a machine. That is what I think is suppose to happen, am I right?

So, my questions are (these questions are "in general" I understand "it all depends" and things can be different for special cases.)

1. Is the machine that I use for the compliance test the one I will eventually rent/buy - the actual machine, not the same model. Or will this machine normally be a "loaner" machine with the same abilities/functions?

2. If it is a loaner machine would it normally be the same model as the one I would end up buying or renting or is it just some similar device?

(the first two questions don't really matter, I am just curious since I have read so much about how different people react differently to different machines)

3. Does Medicare prefer that I buy or rent? (whatever prefer means, easier, pays more/less, etc) In other words, is it easier to get approval for renting vs buying.

4. Since I have both CSA's and OSA's, and I don't have any symptoms of heart failure or left ventricle flow reduction, my research would indicate that the ResMed AirCurve 10 ASV machine would be the "best" for my case? It is also one of the most expensive by twice the next model down. Does medicare/Humana care? Or if the doctor writes the script for the ASV will they simply rubber stamp it?

5. If the ASV machine is likely to not be approved initially, what is the best second choice to ask for - AirCurve 10 S or VAuto would seem to be the BPAPs from MedRes that would be used in my case (BiLevel worked best in the titration).

6. Assuming I get a machine and it doesn't work out for whatever reason, how hard is it to get Medicare/Humana to replace it with an alternative or am I stuck with that one until some time elapses (years?) and they approve a replacement? (This obviously would impact I hard I push for my choice vs a doctor recommendation that might be different)

7. Do doctors in general script for function and leave the specific vendor and model up to you?

8. The ResMed seems to be more expensive than many alternatives but are highly reviewed in general, I prefer quality over cost, but my concern is that medicare may prefer cost over quality, do you have any advice on getting the high priced spread approved?

9. Are there any advantages to renting the CPAP machine for 13 months and then owning it according to medicare, as compared to simply buying the machine up front by paying my 20% - cost, warranty, etc. Is one option easier to get approved than the other?

10. I am fairly certain I will want a humidifier and the climate control hose regardless of if the doctor wants to add those to the script (I don't even know if they do that) so, I assume I will have to buy those separately and get reimbursed by Humana for the part they may cover, is that true? Or do I pay less out of pocket if the doctor puts those items on the script?

11. Any other options you would recommend for the ResMed AirCurve machines?

Thanks in advance for any information or advice in how to move forward from here. I am excited to possibly solve my constantly being tired and want to do everything I can to expedite this process.

[foss]

Hi Frank,

I can only address a small number of your questions and only from my personal experience. I am still working so I have good insurance and not Medicare. (Not that Medicare is not good, I am just commenting on my personal insurance.)

1 & 2. I have the same machine that I used during the trial period. It was slightly used and had a been a trial machine for someone previously. I guess it wasn't suitable for them or they were not "compliant". By compliant, it means that you use your machine at least four hours per night for 70% of the nights during the first three months. I may be wrong on the exact numbers, I am sure it varies and may be different with Medicare. I have been using the machine for almost a year and I am still 100% compliant. It works so well for me, I will always use a xPAP as long as I have a choice. I did try a number of different "loaner" masks. I can't breathe reliably though my nose so I settled on a Simplus FFM and the Amara View "hybrid" FFM. The Amara View is the one I generally use but have the Simplus as a backup when I have a cold or allergies. The Simplus just seems to work better under those conditions. Once I decided on the best masks for my use, I received new ones, not the loaners.

10. For me, the ClimateLine (heated hose) was mandatory. I was not able to receive a sufficient amount of moisture without it. The amount of humidity that one prefers is an individual thing and you may or may not need it. It is a low cost item in any case.

Many of your other questions are either medical questions best answered by your doctor, or financial questions that will have to be figured out with your Medicare provider and the DME. I was very fortunate, while I know that my DME is making quite a bit of money from my insurance company and 20% from me, they have treated me well and seem to listen and care about my needs. That is not always the case from what I read here.

I am sure others will have a lot of information to fill in the blanks that I cannot.

Jeff

[justMongo]

Too many questions and too many unknowns to answer.
Especially since you have a PPO insurance.

The doctor can write the script in a wide language; or in a strict, specific language.
The latter can specify exactly what they are to dispense; the former give Apria latitude to dispense anything that marginally fits the script.
Beware of Apria, their reputation is lower that a used car salesman selling bridges in Brooklyn.

Best advice is to try to get an ASV machine on first pass.

[bwexler]

I am new here and to Apnea in general. Just finished my second sleep study (titration) and I will be visiting the doctor this week to get the results and the script (hopefully).

I apparently have both OSA and CSA and during the titration study the technical was unable to tune out all the Centrals, and tried to find a balance (She asked me not to tell the doctor she said so because it is not her place to interpret the study, but she said I was throwing a LOT of CSAs). The doctors comment after the first study was that I had severe OSD. I trust him.

Now, I am trying to prepare for the next meeting where I am assuming the CPAP machine will be in my future and I have a few questions before I meet with him.

Background:

I am 66 and have Humana Medicare Gold PPO, which apparently pays 80/20 with 0 deductible (if I am reading the plan correctly) for the DME if the equipment is purchase from an in network DME supplier which it will be - the closest to me is Apria. In my titration study we settled on the AirFit F10 and BiLevel CPAP at high pressure (as high as she could get it without the F10 leaking too much) or a CPAP at lower levels, she wasn't sure which way the doctor was going to lean, it was a balancing act between OSAs and CSAs.

I also understand (I think) that there will be a 30 day compliance test, where I use a device for 30 days and then the doctor determines if I used it and if it was helping. If both are true, I will then get a pre-authorization to buy or rent a machine. That is what I think is suppose to happen, am I right?

The requirement is to use the CPAP for a minimum of 4 hours a night for 70% of the nights in any 30 days within the first 90 days.

So, my questions are (these questions are "in general" I understand "it all depends" and things can be different for special cases.)

1. Is the machine that I use for the compliance test the one I will eventually rent/buy - the actual machine, not the same model. Or will this machine normally be a "loaner" machine with the same abilities/functions?

You will be issued your permanent machine, unless it is determined that the machine can not treat your condition adaqutely.

2. If it is a loaner machine would it normally be the same model as the one I would end up buying or renting or is it just some similar device?

(the first two questions don't really matter, I am just curious since I have read so much about how different people react differently to different machines)

3. Does Medicare prefer that I buy or rent? (whatever prefer means, easier, pays more/less, etc) In other words, is it easier to get approval for renting vs buying.

Humana follows the Medicare guidelines for rental only then you own it after a specific number of payments. My ASV was 10 months with Humana.

4. Since I have both CSA's and OSA's, and I don't have any symptoms of heart failure or left ventricle flow reduction, my research would indicate that the ResMed AirCurve 10 ASV machine would be the "best" for my case? It is also one of the most expensive by twice the next model down. Does medicare/Humana care? Or if the doctor writes the script for the ASV will they simply rubber stamp it?

Yes. Based on your statements I would have the doctor write the prescription for exactly what YOU want in detail, than add the statement "Dispense exactly as written ".

5. If the ASV machine is likely to not be approved initially, what is the best second choice to ask for - AirCurve 10 S or VAuto would seem to be the BPAPs from MedRes that would be used in my case (BiLevel worked best in the titration).

Insist on what you want.

6. Assuming I get a machine and it doesn't work out for whatever reason, how hard is it to get Medicare/Humana to replace it with an alternative or am I stuck with that one until some time elapses (years?) and they approve a replacement? (This obviously would impact I hard I push for my choice vs a doctor recommendation that might be different)

If they palm off a lesser machine you will have to prove medical nessecity before an upgrade. See 5 above.

7. Do doctors in general script for function and leave the specific vendor and model up to you?

Not if you insist he writes what you tell him to.

8. The ResMed seems to be more expensive than many alternatives but are highly reviewed in general, I prefer quality over cost, but my concern is that medicare may prefer cost over quality, do you have any advice on getting the high priced spread approved?

It is the Cadillac, if that is what you need it will be approved if the sleep study indicates it is necessary.

9. Are there any advantages to renting the CPAP machine for 13 months and then owning it according to medicare, as compared to simply buying the machine up front by paying my 20% - cost, warranty, etc. Is one option easier to get approved than the other?

Yes. It is the only way to get Humana to pay.

10. I am fairly certain I will want a humidifier and the climate control hose regardless of if the doctor wants to add those to the script (I don't even know if they do that) so, I assume I will have to buy those separately and get reimbursed by Humana for the part they may cover, is that true? Or do I pay less out of pocket if the doctor puts those items on the script?

Yes it should all be in the script. The humidifier will be billed seperately as a purchase, but should be on the script. It is also built into the AirCurve line so you will get it.

11. Any other options you would recommend for the ResMed AirCurve machines?

Thanks in advance for any information or advice in how to move forward from here. I am excited to possibly solve my constantly being tired and want to do everything I can to expedite this process.

[FrankNichols]

Beware of Apria, their reputation is lower that a used car salesman selling bridges in Brooklyn.

Yes, I have heard that. Which is partly why I have to many questions, I want to have a good idea of what is normal and not when I speak with them.

Best advice is to try to get an ASV machine on first pass.

Okay, I will push in that direction with my doctor and see if he is resistant and if so why.

Thanks

[OpalRose]

As far as coverage with Medicare, call and ask what your coverage is because there are different Medicare Policies.

My Advantage plan paid for a 13 month rental, then I owned the machine. I have a $150.00 deductible on supplies, then pay 20%. So often times its cheaper to buy supplies online.

You do have to meet Medicare Compliance rules within the first 90 days, and also must have a face to face appointment with your doctor after the first 30 days, but before the 90 days is up.

My advice is don't believe anything Apria or any DME tells you especially about insurance coverage. Call your insurance yourself so that there are no surprises.

[FrankNichols]

The requirement is to use the CPAP for a minimum of 4 hours a night for 70% of the nights in any 30 days within the first 90 days.

Thank you very much, that clarifies what I thought.

You will be issued your permanent machine, unless it is determined that the machine can not treat your condition adaqutely.

Okay, good, the point of that question was to be aware so I was not "stuck" with a clunker the supplier is trying to unload, but to make sure the trial machine is acceptable to me.

Humana follows the Medicare guidelines for rental only then you own it after a specific number of payments. My ASV was 10 months with Humana.

Okay, great, I will then expect to rent the trial machine after the trial period. (I think my Humana/Medicare rent to own period is 13 months.)

Yes. Based on your statements I would have the doctor write the prescription for exactly what YOU want in detail, than add the statement "Dispense exactly as written ".

ah, great! I was afraid they had to simply specify the functions, and then the supplier to sell anything to meet those - thank you for the advice.

If they palm off a lesser machine you will have to prove medical nessecity before an upgrade. See 5 above.

Got it, that is at least part of the reason for all the questions - thank you.

It is the Cadillac, if that is what you need it will be approved if the sleep study indicates it is necessary.

Okay, so, the sleep study will specify what functionality I need, the model will be determined by the doctor and my expressed desires.

Yes. It is the only way to get Humana to pay.

Okay, great, I don't mind either way, and will just keep that in mind if the supplier wants me to buy up front.

Yes it should all be in the script. The humidifier will be billed seperately as a purchase, but should be on the script. It is also built into the AirCurve line so you will get it.

Than you for helping me with these questions, I appreciate your time.

[justMongo]

Some advice about Apria I have garnered from others who have used them.
1) Be careful what you sign. Read it.
2) Never give them your credit card number. (They have been quoted as saying, "You signed it, we can charge you whatever we want.")
3) You never have more leverage over any DME that before you take delivery.
4) Be prepared to walk away -- just like with car dealers.

Also, get copies of your PSG reports and your prescription.

[PoolQ]

1. Is the machine that I use for the compliance test the one I will eventually rent/buy - the actual machine, not the same model. Or will this machine normally be a "loaner" machine with the same abilities/functions?

Pretty sure it depends on your DME and maybe if they have a used one available. With my DME it was a brand new one. I would suggest that you get the clinician manuals and know how to get into that menu (or have the DME show you) the number of hours on the machine. If it is used then after you are compliant and they change you to a rent to own, make sure they give you a brand new machine.

2. If it is a loaner machine would it normally be the same model as the one I would end up buying or renting or is it just some similar device?

not much point if it's not the exact same one. see what you want in the script below

(the first two questions don't really matter, I am just curious since I have read so much about how different people react differently to different machines)

3. Does Medicare prefer that I buy or rent? (whatever prefer means, easier, pays more/less, etc) In other words, is it easier to get approval for renting vs buying.

I don't know for sure about Medicare, but my insurance is supposed to follow the Medicare guidelines and they will only do rent to own. This is controlled by insurance and not the DME, Doctor, or you (unless you are not using insurance)

4. Since I have both CSA's and OSA's, and I don't have any symptoms of heart failure or left ventricle flow reduction, my research would indicate that the ResMed AirCurve 10 ASV machine would be the "best" for my case? It is also one of the most expensive by twice the next model down. Does medicare/Humana care? Or if the doctor writes the script for the ASV will they simply rubber stamp it?

Here is my experience: My doctor asked me what machine I was going for and then made a plan to get me what I wanted. Again depends on insurance. I had to try APAP first and fail to get to VPAP (BiLevel) this required two titrations. If I had wanted an ASV that would have required failing APAP and yet another sleep test. Understand that CPAP therapy can cause centrals and yours may go away after a while. IE they are not real and are CPAP induced, or of course they may indeed be real.

5. If the ASV machine is likely to not be approved initially, what is the best second choice to ask for - AirCurve 10 S or VAuto would seem to be the BPAPs from MedRes that would be used in my case (BiLevel worked best in the titration).

VAuto is not a BiLevel from Resmed (pretty sure at least) AirCurve VPAP is the basic BiLevel.

6. Assuming I get a machine and it doesn't work out for whatever reason, how hard is it to get Medicare/Humana to replace it with an alternative or am I stuck with that one until some time elapses (years?) and they approve a replacement? (This obviously would impact I hard I push for my choice vs a doctor recommendation that might be different)

If the machine works you own it, so make sure it is data capable. If it does not work you will get the next level until the therapy works, not difficult but will take time.

7. Do doctors in general script for function and leave the specific vendor and model up to you?

Varies all over the map. Tell your Doctor what you want and make sure the script says that, Yes you can have it modified if you need to

8. The ResMed seems to be more expensive than many alternatives but are highly reviewed in general, I prefer quality over cost, but my concern is that medicare may prefer cost over quality, do you have any advice on getting the high priced spread approved?

They will supply what your doctor prescribes

9. Are there any advantages to renting the CPAP machine for 13 months and then owning it according to medicare, as compared to simply buying the machine up front by paying my 20% - cost, warranty, etc. Is one option easier to get approved than the other?

10. I am fairly certain I will want a humidifier and the climate control hose regardless of if the doctor wants to add those to the script (I don't even know if they do that) so, I assume I will have to buy those separately and get reimbursed by Humana for the part they may cover, is that true? Or do I pay less out of pocket if the doctor puts those items on the script?

It is not standard on any machine, even the Resmed machines have a plastic end cap that you can get. You need to have it prescribed with a heated hose.

11. Any other options you would recommend for the ResMed AirCurve machines?

[trish6hundred]

Hi FrankNichols,
WELCOME! to the forum.!
I wish you good luck as you work through the process of getting the machine you want, and much success to you as you continue your CPAP therapy.