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Airsense 10 NEW with 360 Run Hours
#11
RE: Airsense 10 NEW with 360 Run Hours
So I have Aetna Better Health of PA (Medicaid), and I guess I am lucky because here's what they say:
   
   

Here's what I got from the DME, and because the headgear resupply is 6 months, and the DME's policy is to only supply cushions or whole masks, they won't resupply the frame at 3 months.  So, I know the mask doesn't normally wear out that quickly, and many people are receiving "unneeded" supplies, but as a newbie, I am eager to get a backup for each component in case there is a failure (or so I can alternate if one gets wet).  So, I'm thinking a new cushion each month, a new frame every 3 months, and headgear every 6 months, but I guess in DMEland, its 3 cushions every 3 months and a whole mask every 6 months.  I guess I'm just nitpicking.  But given how slowly everything thus far has gone, my concern is that things that are scheduled for 3 months, I'll receive after 6 months; and things scheduled at 6 months, I'll receive after a year.  So I remain grateful to have received the equipment I need fully covered by insurance, but vulnerable because I can't afford anything out of pocket.  

   

On a happy note, after a pre-CPAP sleep study of AHI 50, my first night scored AHI 0.68 - just 2 OAs in 7 hours.  Although it was excruciatingly painful and difficult to endure, despite having had a positive experience at the sleep study.  This forum is so valuable to put one's struggle in perspective and know you are not alone.  I feel like crap, but hey its a process, right?  Thanks all!
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#12
RE: Airsense 10 NEW with 360 Run Hours
I am told that Aetna Better Health follows PA Medicaid resupply schedule.

A7034 1 every 6 months
A7035 1 every 6 months
A7037 1 every 90 days
A7030 1 every 6 months
A7032 2 every month
A7031 1 every 90 days

But, that's just the information I have.

Good luck with your cpap
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#13
RE: Airsense 10 NEW with 360 Run Hours
(03-06-2019, 09:55 AM)dmeRT Wrote: I am told that Aetna Better Health follows PA Medicaid resupply schedule.

A7034 1 every 6 months  
A7035 1 every 6 months
A7037 1 every 90 days
A7030 1 every 6 months
A7032 2 every month
A7031 1 every 90 days

But, that's just the information I have.

Good luck with your cpap

Thank you for the information.  Are you with an actual DME in PA, out of curiosity? 

So I just spent the last couple hours trying to talk to Aetna Better Health of PA.  
They've never heard of a "CPAP machine", but they had heard of an "E0601".


My question: Is it ok that I was dispensed a used CPAP machine for an authorized prescription for an E0601?
Answer: and I quote, "Whatever the durable medical equipment company provided to you is what is covered by your benefits."

2nd question, and I was specific because they can only handle one insurance code at a time: 
How frequently can I get a replacement A7031 CPAP Full Face Mask Cushion because my prescription says every 30 days?
Answer: "We do not have that information at this time, but it would be whatever frequency was on the authorization."  (meaning authorized prescription)

So my prescription says cushion every 30 days, I guess we will see...I was told I can't get any resupplies at all until I complete the 90 day compliance period.
I wish I could get a ResMed rep in the same room as my sleep doctor and respiratory therapist and knock there heads together until they give a single answer.

P.S. Yes, I know I am taking this all too seriously. If I sound grumpy, I'm sorry, maybe I just didn't sleep well last night.
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#14
RE: Airsense 10 NEW with 360 Run Hours
(03-06-2019, 08:36 AM)dmeRT Wrote:
(03-05-2019, 08:54 PM)snord Wrote: No, I didn't pay anything out of pocket (Medicaid).  I am grateful to get any equipment and excited to get started, as this has been an ordeal of waiting since October 2018.  But Medicaid follows Medicare guidelines.  I found one post where a person was told a unit under 500 hours was considered "new."  I have scoured the medicare legal code trying to find anything specific, but no luck on what the rules are.  I was told point blank that this was a new machine.

I am leaning towards just keeping it because I am fearful of harming my relationship with the DME.
This was the best of the few medicaid choices in my area.

Medicaid does not follow medicare guidelines for resupply.

However I do believe that medicaid contracts with DME companies require "new" machines.   Not new/used.  Might try to contact your medicaid provider and tell them what you got and ask them what they think.
That sounds like good advice.  It can't hurt to check with a different DME provider to find out what the rules are.  Alternatively Snord, you could check with the medicaid office in your state to see what the rules are.   If by chance, you caught the DME breaking the rules, they should replace your machine with a new one, same model (if that is indeed a requirement in your state).
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#15
RE: Airsense 10 NEW with 360 Run Hours
Most of the components will last much longer than the replacement schedule. I have been using the same heated hose for about a year and expect it to last much longer. I've gotten a year or more out of humidifier chambers. I thought my resmed humidifier developed a small leak after 9 or 10 months but after checking it more carefully discovered I was wrong. I've been using my original F20 AirFit cushion and mask for almost 24 months. You will probably not get much life out of the memory foam cushion. there have been reports on the forum that it does not hold up as well. I may be an extreme case but I think many of the veteran members of the forum replace components much less frequently than the schedule you were given.
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#16
RE: Airsense 10 NEW with 360 Run Hours
(03-06-2019, 12:34 PM)snord Wrote:
(03-06-2019, 09:55 AM)dmeRT Wrote: I am told that Aetna Better Health follows PA Medicaid resupply schedule.

A7034 1 every 6 months  
A7035 1 every 6 months
A7037 1 every 90 days
A7030 1 every 6 months
A7032 2 every month
A7031 1 every 90 days

But, that's just the information I have.

Good luck with your cpap

Thank you for the information.  Are you with an actual DME in PA, out of curiosity? 

So I just spent the last couple hours trying to talk to Aetna Better Health of PA.  
They've never heard of a "CPAP machine", but they had heard of an "E0601".


My question: Is it ok that I was dispensed a used CPAP machine for an authorized prescription for an E0601?
Answer: and I quote, "Whatever the durable medical equipment company provided to you is what is covered by your benefits."

2nd question, and I was specific because they can only handle one insurance code at a time: 
How frequently can I get a replacement A7031 CPAP Full Face Mask Cushion because my prescription says every 30 days?
Answer: "We do not have that information at this time, but it would be whatever frequency was on the authorization."  (meaning authorized prescription)

So my prescription says cushion every 30 days, I guess we will see...I was told I can't get any resupplies at all until I complete the 90 day compliance period.
I wish I could get a ResMed rep in the same room as my sleep doctor and respiratory therapist and knock there heads together until they give a single answer.

P.S. Yes, I know I am taking this all too seriously.  If I sound grumpy, I'm sorry, maybe I just didn't sleep well last night.

Insurances and there codes.... 

An E0601 is a cpap machine.
A7031 is the full face cushion  (every 90 days for PA Medicaid)

really doesn't matter how often the doctor writes for resupply.  insurance will only pay according to their guidelines.   If the DME bills the insurance every month for this cushion, DME's won't get paid for it. 

As far as getting a used machine...cpap's are often given out as "new" with hours on them.  But the DME might be violating their medicaid contract by doing so... some insurances care, some don't.  300+ hours really isn't that much and as others have stated not that big of deal.  especially since you have no monetary investment.  they should have been more prudent and disclosed the "new/used" machine and the warranty should start anew from the date you received the unit.  

I am involved with a DME that covers an area in both PA and NY...
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#17
RE: Airsense 10 NEW with 360 Run Hours
Yes, I've decided to keep the machine and focus on compliance.  After all, I got my dream machine (bad choice of words, since its a ResMed and not Respironics), yay!

I really appreciate everyone's input.

dmeRT, thank you for explaining the DME's perspective.  I got off on the wrong foot a little with my DME, mostly because they could(would) not answer my questions directly, and started explaining "policies" about things that I had previously asked about and turned out to be very different than I had expected.

I still feel I will have no clear answer on supplies until my compliance period ends, and I am allowed to sign up for their "re-supply" program.  It was frustrating to get no information from Aetna and realize the prescription is really no indicator either.  The DME provided recommended frequencies, like 3-6 months, and the RT crossed out the 3 to suggest it would be 6 months, so is that because most people don't need a replacement at 3 months, or because the insurance doesn't cover it, and I can't get one even if it has broken.  I guess I just have to hope for the best...


I will be exploring other options, but with medicaid my choices are limited; I'm guessing there are no online options.
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#18
RE: Airsense 10 NEW with 360 Run Hours
My DME, and I suspect most, very much wants me to replace components as frequently as my insurance allows. They make more money. I regularly get calls reminding me that I haven't replaced my mask per their recommendations with the suggestion that I am putting my health at risk by not replacinf cushions monthly, masks every three months, etc. I ignore them and my health is fine. I suspect if they changed your frequency it's because that is what your insurance will cover.
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