Convincing DME or my insurance?

[thegoobs]

Hi all, I just started cpap therapy this week and had a terrible time with the Apex Auto XT the DME sent me (after 2 months of waiting). I had such a hard time on the exhale, that I couldn’t last more than 3 hours each night. I felt so terrible the next mornings. 

I ended up borrowing a friends ResMed Airsense 10 Autoset last night, with the same settings from my sleep study. I had the first great night of sleep in probably 2 years! The unit said I had an AHI of 5.1.  I was at 32.8 AHI during the sleepy study. This Airsense unit was much more comfortable and no issues on the exhale. I really need this unit for myself now!

My question is, do I need to convince the DME to give me the Airsense? Or the insurance? The interesting thing is that my sleep study report specifically recommended the ResMed Airsense 10 unit

[Nightynite]

Your pcp just needs to write a prescription for the exact model. It’s actually pretty simple. Plus you can use that script to buy one online out of pocket if need be. Welcome

[KeepSmiling]

Go back to the DME.

Did you have a prescription, if yes what did it say? If they do not agree to change it make sure the doctors prescription has the name on it.

I do not know if the sleep study report qualifies as a prescription.

Unless rules changed, I think both autoset cpaps have the same medical code for insurance purposes.

[Brazen]

What are the settings in the Apex vs. AS10?
That could be part of the problem. But I don't know if the Apex is compatible with OSCAR software so you wouldn't be able to monitor your treatment. 

The ResMed Autoset 10/11 both seem to be oft recommended machines. There is a pinned thread about machines toward the top of this forum. Read it.
You really want a machine compatible with OSCAR so you can see your data and adjust settings to optimize treatment. 

Choose a good machine and get the script from your sleep doc specifying exact machine.
Or buy one from an online supplier. 
Cost through a DME tend to be high so it depends on your insurance whether it makes more sense to private pay.

[sunsaffron]

Based on what you've mentioned, I suspect you'll have to convince the DME to supply the correct machine. If your script specifically mentioned the ResMed, your DME will have a much more difficult time pushing back. Alternatively as others have mentioned, as long as you have your prescription, you can buy online out of pocket.

[clownbell]

I have read that it helps for the script to specifically name and make and model machine and ALSO say "Dispense as written. No exceptions." Then the DME has no wiggle room.

As I understand it, CPAP machines have the same billing code number. Insurance companies use billing codes. So if the DME can give you a cheepie they get paid the same and will make more money than if they gave you a quality machine. Not pointing the ugly finger at anyone, but - - - - -

[booksfan]

I have read that it helps for the script to specifically name and make and model machine and ALSO say "Dispense as written. No exceptions." Then the DME has no wiggle room.

As I understand it, CPAP machines have the same billing code number. Insurance companies use billing codes. So if the DME can give you a cheepie they get paid the same and will make more money than if they gave you a quality machine. Not pointing the ugly finger at anyone, but - - - - -

Interestingly enough, my prescription when I started on CPAP DID specifically name a machine make and model but when the DME called me, they told me that I could not have the specified machine. They said "everybody gets the same machine" but you can have a choice of mask.    I said that I had discussed machine choice with my doctor and we had decided on the machine on the prescription and they reiterated "everybody gets the SAME machine." Quick call to my doctor and I was set up with another DME!

You really do have to advocate for yourself!

[thegoobs]

Ok, I’m going to check to see if my DME can just make the change. If they can’t, I’ll ask my doctor to give me a script specifically for the ResMed Airsense 10 auto set. Luckily my friend is letting me use this unit while I sort the situation out. I have had 2 amazing nights of sleep with the ResMed unit. 

I’ll reply here with the outcome of dealing with the DME and doctor office.

[clownbell]

Another idea if DME won't budge. Post on this board, indicating that you need a ResMed AirSense 10 AutoSet. You may get some responses regarding brand new machines and/or gently used machines with low run hours.