Justifying new Cpap machine

[sleepy_one]

I was able to talk my doctor into ordering a new machine for me because my old one was 10 years old AND was noisy. She said age alone was not enough reason justify a new machine to insurance.

The same doctor would not replace my husband's 5 year old machine because there was "nothing wrong with it". Does that seem right? From reading this forum I got the impression that people were regularly able to replace 5 year old machines based on age alone.

The doctor ordered a home study with a 30 day rental of a fully data capable machine for my husband, but I wish she would have just gotten him that machine to own instead of just rent.

[drgrimes]

I am shocked at your doctor's attitude. Why would the doctor care? It's an insurance or medicare and your financial issue. The doctor normally only writes the RX for the DME. The DME gets you whatever the RX says and he files it on your insurance. Have you asked the person that actually dispensed your cpap machine?

[PaulaO2]

The doctor is not the one to determine the insurance qualifications. Usually that is the supplier that does that. Unless the doctor is also the supplier. In that case, go to another doctor. And it is not just the general age of the machine, it is the firmware inside the machine and how it reports the data. The advances in the machines and how well they are able to treat events now compared to 10 yrs ago is amazing. Just as there are better anti-cancer drugs.

Age of the machine alone is usually not the only criteria, true, but usually after 5 years, a CPAP machine has issues, even with good care. Any supplier knows how to bull crap the insurance form to "justify" a new machine. It's how they earn their money.

[RockABye]

I'm no expert, but I think a lot depends on your insurance company. I would recommend that you call your insurance company and find out what their requirements are. That way you're armed with the info when you go back to the doctor and can tell her "my insurance says that they pay for a replacement machine every "x" years, so with the improvements in the CPAP technology, I want a prescription for a new machine." If she gives you any lip over it, find a new doctor. You might want to do that anyway. Is this doctor a sleep specialist? I'm guessing that she's a general practitioner, and there's nothing wrong with that, but my experience is that they don't tend to be very well trained on CPAP and sleep apnea issues. You're right to be asking questions because ultimately, you're your own best advocate to insure you get the proper health care.

I'm sure you'll get more responses from members who have a LOT more experience with CPAP and insurance issues. Good luck!

[cbramsey]

Medicare guidelines allow for a new XPAP machine every 5 years unless your circumstances dictate a new machine sooner.

Good luck to you.

[justMongo]

CPAP machines do have accidents. I think my old S8 is about to come in contact with a Taser.

[sleepy_one]

Thanks for the replies! This forum has been very helpful!

This whole experience has been so frustrating and exhausting. I have had to fight every step of the way to keep the equipment supplier from overcharging us. They said we could each return one mask and headgear that did not work for us, and then tried to get us to keep them saying "insurance will pay for it". That's not true, as they only pay for headgear every 6 months. Then they said, "Well, if insurance doesn't pay you will just have to pay out of pocket." I said no way, and they finally took back the masks and headgear. There have been so many other things like that that I can barely keep track. We had a change of insurance and are now being forced to use this company, unfortunately.

I am now worried about the heated hose the equipment company sold me. Will medicare pay for a heated hose a month after they paid for a non-heated one? They said "it's a different code" but what does that mean?


And now I'm feeling that the doctor is costing us money too, as she ordered the expensive at home study instead of a new machine, which is what I think my husband will eventually end up with. (She is a sleep specialist and seems really good except for this new machine issue.) So then we will end up paying for the home study and machine rental AND a new machine.

[PaulaO2]

A home sleep study is a good thing as we sleep better at home than away.

If you are paying out of pocket, check out Supplier #2 in our Supplier's List (link at top of every page).

They probably will pay for the two hoses. They are so one-track-minded when it comes to the codes.

I also suggest you look for another supplier. The one you have now is out to get whatever they can out of you.

[me50]

my machine came with a standard hose but my script had a heated hose so when I got my machine, I got the heated hose but the standard hose came with it so they gave it to me. As long as you have a script for it, you should be okay. Should being the operative word.

My DME, billed my insurance company and got paid for 2 masks but I only got one.

your DME sounds like the one that I have been dealing with. I think there are one or 2 more on here with the same DME.

[PaulaO2]

me50, that is called insurance fraud. You should report it. Even if they don't do anything, they make a note of it. If enough people reported it, there would be enough notes to be taken seriously.