Ready to buy CPAP machine

[NewlyDiagnosed]

Hello, It's about one month from my Lofta sleep test and I'm ready to get a machine.  I've read a lot on this board and I know that I want the Resmed 11 (probably female version?), and hoping that nasal pillows will work.  I gathered from reading here that it is often not cost-effective to go through insurance so I've been assuming that I would buy the equipment online.  But I went through the insurance approval and cost estimate process (more than 3 hours on the phone) and it looks to me like it would be much less expensive to go through my insurance company.  If anyone could tell me whether I'm missing something, I'd appreciate it.

My deductible is only $500, and I've already used about half of it.  After that, I would pay 20%.  The machine would be rented for 10 months (rental cost $84/month), and after that time I'd own it.  The estimate for the first month's rental and the initial mask, tube, etc., purchases is $327, starting the 2nd month my monthly rental for the machine would be $17 and I'd pay 20% of the cost of supplies, accessories, etc.  The Resmed system at the online seller I was looking at is something like $850, which is about the total 10 months rental costs.  So I'm thinking it makes sense to go through insurance?

There are some things that are making me anxious, though.  I have read here that Medicare requires an in-person visit to a doctor.  My sleep test was interpreted, and the prescription written, by an MD 3000 miles away who does this for Lofta.  I have tried to get an appointment with a specialist here, but the first available was in December.  I'm not going through Medicare, but I'm worried that my insurance company may have the same requirement.  If they do, would I be able to get my primary care doctor to write a prescription?

I'm also a bit worried about the compliance issue.  My insurance company will review 30 days of data sometime during the first 90 days.  It could be any time from the beginning to the end, and I'm worried that if they monitor at the beginning, I may not be in compliance because of start-up problems. 

I've read enough to know how to deal with the DME company, how to insist on particular machines, how to check hours used, etc.  I will have to call my insurance company on Monday to find out what the DME choices are.  (I have to use one of their DME providers or go to a much higher deductible/coinsurance.)  I checked their DME providers online, and there seem to be only a few that handle CPAP machines.  I didn't see any within an hour of my house.  If they're too far away, can I have them just send me the machine, or do I have to let them set it up, fit me for masks, etc?  In general, I'd rather just have the machine sent to me to set up myself; would I be able to do that?  I do see some value in being able to try different masks.

I'm a month from my diagnosis (moderate apnea, AHI about 20).  For the first couple of weeks, I wasn't convinced that I had it, and I tried changing sleeping positions and sleeping on a wedge.  Then it took some time to go through the insurance company and the company they use for approvals.  I'm in the system now and the approval should come quickly, unless something comes up (like a doctor 3000 miles away). I am now sure that I have apnea and I'm eager to get a machine.  I would be very grateful for any advice (and I am very grateful for all the knowledge I've gained from this site).

[HalfAsleep]

Woah, Nellie! I think you’re maybe getting a little ahead of where you actually are…

First, you’d have to figure out what kind of machine is appropriate, since there are different models for different kinds of apnea, as well as different therapeutic settings, and different airway responses therapy.. There might be folks on here who can help you figure that out. There are definitely ways to get machines without involving an insurance company.

Second, if CPAP is the option that corresponds to your diagnosis, Resmed makes an Airsense 10 Card to Cloud, for much less money than you’re thinking (maybe just half). The only feature it doesn’t have is a modem that uploads your compliance to your doc and/or your DME. Skip them, and just buy direct with the prescription. Buy new, from lots of online choices. You can see this board’s list of vendors for favorites.Big caveat: CPAP might not be the right machine, so get input first.

Resmed no longer makes the “for Her” model. I believe they incorporated the female algorithm into the current models. I got mine 5 years ago, and it's now been discontinued.

[srlevine1]

Forget about compliance issues. The unknown is magnifying the issue in your mind.

According to CMS (Centers for Medicare and Medicare Services) and most insurers, the minimal compliance goal is to use a device for a minimum of 4 hours per night for 70% of the time within a consecutive 30-day period within the first 90 days of having the equipment. Most people have no issues meeting this goal since they can meet this limit by wearing their masks while awake and waiting to fall asleep.

Once you get your machine, you can set "comfort items" like ramp time (the period during which the therapy pressure increases from a low start pressure to the prescribed treatment pressure) and EPR ( expiratory pressure relief). These make it easier to exhale to deal with mask learning and compliance issues.

As for the in-person visit, see if your doctor will agree to consider a telehealth visit over Zoom as an in-person visit for Medicare or insurance compliance purposes. Through December 31, 2024, all providers who are eligible to bill Medicare for professional services can provide distant site telehealth. Currently, Medicare patients may use telecommunication technology for office and hospital visits and other services that generally occur in person.

You may wish to post a copy of your sleep study (without personal information) for forum members to review and make suggestions on an appropriate device.

For the Card to Cloud version of my device, my DME sends me a postage-paid envelope so I can send them the SD card to upload to ResMed's AirView platform for compliance and monitoring purposes. I then insert another SD card to capture the next period of data. They return my previously submitted SD card with another postage-paid envelope and a copy of my AirView report, and the process repeats.

I would also suggest downloading and installing OSCAR to monitor your therapy and seek more applicable advice from forum members.

BTW: First, as for cost, what value do you place on your health? Second, when you amortize the cost over the five-year life of the machine, it is almost inconsequential.

Best of luck. -- Steve

[NewlyDiagnosed]

       
Thank you very much for the reassuring comments, Steve.  Yes, that compliance arrangement is what they described.  And it sounds like the in-person doctor visit won't be an issue, because I had a call today from the company that handles the approvals for my insurance company. Apparently I'm approved, because she said that they would call the DME companies during the week because they aren't open on weekends.  The compliance company has been great.  One guy who helped me has sleep apnea and we had some interesting conversations during long periods on hold with my insurance company.  He told me that almost every one gets the ResMed 11.

The ResMed AirSense 10 and 11 were recommended by Lofta based on my sleep study, and I've read the reviews here. The prescription specifies an APAP machine.  I'd love to hear other opinions, though.  I'm posting my study results below. I am planning to get an SD card and to use Oscar.  

I was pleasantly surprised to learn that I have good insurance coverage for this, but I was prepared to just buy the machine myself, and I will do that if something goes wrong with the insurance company.  I was surprised to learn that I have SA, and it took me a couple of weeks to accept the diagnosis, but at this point I'm eager to get started with the machine and possibly stop being tired all the time.

[srlevine1]

Your sleep report is rather rudimentary compared to most I have seen.

Personally, my preference is for the ResMed AirSense 10 AutoSet because it has a more robust motor (IMHO), a better filter, and fewer gamified electronics to malfunction. The 11 also has a crappy water chamber and no swivel hose connection. On paper, the 11 has some form factor and functionality improvements, but I am sticking with what worked for me for over 5 years.

In fact, I got a new S10 unit and had the old S10 reconditioned as a zero-time spare. For me, robustness, resiliency, and reliability are the important factors. Since I do my own tracking, connectivity is not an issue. The deciding factor is I already own the expensive pulse-oximeter kit, and the DC-DC converters for battery use.

If I was paying out-of-pocket, I would go with the ResMed AirSense 10 AutoSet card-to-cloud.

[NewlyDiagnosed]

Yes, I've read some comparisons of the 10 and 11 and I recognize that there are advantages to the 10.  And the Lofta prices were the same for the 10 and 11 (the 10 was the connected version).  And my cost with insurance would be the same for any machine. But the 11 has the female program, and my son uses this machine and is happy with it.

[NewlyDiagnosed]

I now have the name of the DME company; checked their website and they have both the ResMed 10 and 11. Do the advantages of having the female program (11) outweigh the advantages of the 10, which most people here seem to like better? the cost to me would be the same.

[Nightynite]

I have a for her model for a back up machine and I tried the “ for her setting “ it wasn’t for me.
Even though I’m a male, my wife didn’t like it either compared to my A10.
Some people must like it, it’s an individual choice that you would just have to try.

Even on the for her model , you can turn off the setting and then it’s just like the A10.

[BoxcarPete]

Difference in price through insurance or not is likely to be completely negligible. Your insurance coverage spreads out over two calendar years, so you have your $327 + 17*9 + 84*3, which comes out to $732. AS10 Card-to-Cloud is available from Supplier #1 for $450 (they may have a new-customer sale), and Supplier #42 for $399. Masks usually run about $100 to $150 so the break-even is about three masks before you find one you like, or a six-month replacement if you like the second one you try. That's somewhat under 50-50 odds if you ask me, mask fitting trial and error is not uncommon.

So, if you don't care about the for-her algorithm which as Nightynite states has mixed reviews, and you would rather buy for yourself and not deal with compliance, the price is close to the same. If you want the 11, definitely insurance. Annual doctor update requirements can typically be fulfilled by your regular family doctor; there is no need to see a sleep specialist for that. Tiebreaker would go to the insurance route because you'll have your deductible paid off through CPAP stuff and won't need to worry about that for other kinds of medical expenses.

[Nightynite]

Don’t let my experience have anything to do with your decision. I have been using the A10 for 6 yrs and I’m sure I’m just use to it. When I tried the “for her setting “ I didn’t survive the night before I just switched to the standard setting.