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What is A Nasal Pillow?
#1
I just got off the phone with my DME. According to my insurance, which follows Medicare Guidelines, I thought I was entitled to TWO nasal pillows per month, a replacement for my Swift FX. However, when I called my DME to order the pillows, they explained that I was entitled to only ONE nasal pillow per month. When I complained to my insurance representative that the DME was shorting me, they called the DME on my behalf to claim my TWO pillows.

Well, guess what the DME said to the insurance company? According to Medicare, we are entitled to a SET of TWO pillows, a pillow for each nostril. How ridiculous is this? Nasal pillows only come as a pair. If Medicare had only stated I was entitled to one pillow per month, would they have cut the set in half?

Have any of you run into this? What constitutes a single nasal pillow, anyway? Is my DME interpretation of what Medicare provides correct? Is perhaps the Swift FX different from other nasal pillow systems where with other systems the pillows for each nostril come separately?
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#2
I'm sorry to have a chuckle over this, and believe me this is not at your expense, but this sounds exactly like a stupid, governmental thing! Contents: Bridge, Mask, CPAP, Silicon, clear, 1 ea; Pillow, Mask, CPAP, Silicon, clear, 2 ea.
Gotta love government writers!
Is there a way to contact Medicare and get clarification? I don't have medicare at this point in my life so I honestly don't know. I'm sure it will be a pain, but it would be interesting to get an answer on that!
As always, YMMV! You do not have to agree or disagree, I am not a professional so my mental meanderings are simply recollections of things from my own life.

PRS1 - Auto - A-Flex x2 - 12.50 - 20 - Humid x2 - Swift FX
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#3
HCPCS code: A7033
Description: Pillow for use on nasal cannula type interface only, pair
Maximum replacement allowance: 2 per 1 month
http://www.healthcare.philips.com/pwc_hc..._Hints.pdf
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#4
This is why I never try to get Medicare or the insurance company to pay for pillows. The ones I use are fairly inexpensive (less than $25) and I only replace them about every 2-3 months. I know I'm entitled to change them more frequently; but, I've never had them get hard, discolored, or stinky, and I wash them every week. Dodgy
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. 
ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA.
INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINIONS ONLY AND NOT NECESSARILY STATEMENTS OF FACT.
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#5
(06-26-2012, 03:51 PM)zonk Wrote: HCPCS code: A7033
Description: Pillow for use on nasal cannula type interface only, pair
Maximum replacement allowance: 2 per 1 month
http://www.healthcare.philips.com/pwc_hc..._Hints.pdf

Zonk, thanks for this reference. It appears from this that the DME should be supplying 2 pairs of pillows per month, since the medicare code is defining a pillow as a pair.

This is clearly the case if you look at analogous case or code, HCPS A7032:

Cushion for use on a nasal mask interface, each. (Here a Cushion is defined as EACH.)
Maximum replacement: 2 per month (2 of Each per month)


We can see in both cases of nasal devices you get 2 replacements per month. For a nasal pillow you get 2 pairs of nasal pillows. For a nasal mask, you get 2 cushions.

I will be calling both my Insurance company and the DME with this tomorrow.
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#6
I would tell the DME, "Hey I don't need two pillows each month... I'll be by and pick up only one of them"... and then try to see them cut them in half so you only have one 'pillow'. Too-funny

On a more serious (but troubling) note... I'm wondering if the DME isn't already billing your insurance company for two (complete) nasal pillows each month, and telling you this line of baloney so that they only have to give you one full set of pillows... if they do that with enough patients, it adds up to more profit for the DME.

Might want to mention to the DME that you'll be contacting your state insurance fraud division if they can't "get this resolved". Light a fire under them and watch them squirm.

SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.



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#7
(06-26-2012, 05:04 PM)SuperSleeper Wrote: I would tell the DME, "Hey I don't need two pillows each month... I'll be by and pick up only one of them"... and then try to see them cut them in half so you only have one 'pillow'. Too-funny

On a more serious (but troubling) note... I'm wondering if the DME isn't already billing your insurance company for two (complete) nasal pillows each month, and telling you this line of baloney so that they only have to give you one full set of pillows... if they do that with enough patients, it adds up to more profit for the DME.

Might want to mention to the DME that you'll be contacting your state insurance fraud division if they can't "get this resolved". Light a fire under them and watch them squirm.

I don't think I will have to threaten the DME with fraud. One advantage that I have is I am a physician who is employed by this Insurance company, which is an HMO. Believe me, the Insurance company will be calling that DME once I refer them to these codes. I have a feeling that the Customer service person at the DME made a mistake. I don't think she was a part of conspiracy at the DME to short change a patient or overcharge the insurance company. Why? The respiratory therapist at the DME was the one who originally told me that I was entitled to 2 cushion replacement every month. That's why I was confused by the Customer service person who told me I wasn't. Obviously, the later was mistaken.
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#8
My ins. is Medicare and Medicaid. I only get one complete mask, including pillows, every 3 mos. So one set of pillows lasts me 3 months. With the DME I have, if they could get away with sending me more, they would. So I am surprised they are not. Not that I *need* a new set every two weeks. I make mine last 3 months whether then want to or not! LOL
PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#9
(06-26-2012, 03:51 PM)zonk Wrote: HCPCS code: A7033
Description: Pillow for use on nasal cannula type interface only, pair
Maximum replacement allowance: 2 per 1 month
http://www.healthcare.philips.com/pwc_hc..._Hints.pdf

I only ask this because it came up recently and scanning the article that you linked to I don't see it spelled out (yes, I can be blind) but is this the AUS Medicare or the US Medicare? We already had a discussion earlier in the month establishing that these are two different things so I am just wondering if we are talking apples and oranges here. Call me slow...that's okay!
As always, YMMV! You do not have to agree or disagree, I am not a professional so my mental meanderings are simply recollections of things from my own life.

PRS1 - Auto - A-Flex x2 - 12.50 - 20 - Humid x2 - Swift FX
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#10
(06-26-2012, 07:26 PM)mjbearit Wrote: but is this the AUS Medicare or the US Medicare?
Its US Medicare. Scroll down the blue highlighted HCPCS codes page.

Reimbursement
http://www.apneaboard.com/forums/Thread-Reimbursement

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